Camp Fun Quest Registration Form

Empowered Kids After school Registration
Student Information
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Address*
City*
State*
Zip*
Birth Date*

MonthDayYear
Grade*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
Parent /Legal Guardian 2*
Relation 2*
Work Phone 2*

Area CodePhone Number
Cell Phone 2

Area CodePhone Number
Home Phone*

Area CodePhone Number
Emergency Contact Info
Emergency Contact Name(if parent or guardian is not avaliable)*
Emergency Number*

Area CodePhone Number
Emergency Number #2*

Area CodePhone Number
Sibling

Please complete separate registration for each child, but contact director about multi-child discount registration fees.
Sibling #1
Sibling #2
Email Confirmation
Parents Email (student confirmation will be sent by email, if left blank it will be mailed)
Student Email
Other Information
How did you hear about Empowered Kids
Health Information

This section must be completed in full for NC state health and safety regulations.
Are immunications up to date?

YesNo
Date of last tetanus shot
Any activity the student should be restricted from?
Any physical, mental or other condition that would require special attention or medication?
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.
List any allergies (ex: bees,peanuts, dairy)
Any dietary needs that we should know about?
Student Photo Release
I agree that photos of my child can be taken on used on for social media purposes

YesNo
Payment Information

$25 Registration Fee Due
Method of payment

Credit CardMoney OrderCash
- Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named student, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named student by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites.
Electronic signature, please initials*
Should be Empty:

Empowered Kids After school Registration

Student Information

Parent or Legal Guardian Information

Emergency Contact Info

Sibling

Email Confirmation

Other Information

Health Information

Student Photo Release

Payment Information