CYBC Registration Form

Charlotte Youth Broadcasting™ Camp

Registration Form
For ages 9-12 and 13-17

Cost Per Week (day camp): $445.00 1st child, $395.00 2nd child, $345.00 3rd or more.

Cost for Overnight: $1,375.00 (mandatory $255 deposit).

Lunch is included or [Opt-Out] if opt-out, Parent/Guardian will provide child(ren) lunch (no price adjustment will be provided). **Any allergy (Food and Non-Food Allergies) is an automatic opt-out for lunch. Parent Must provide lunch according to your child(ren) needs. **If you still want your camper to consume camp meals, you Must Opt-In and sign the Mandatory Meal Waiver Form, no exceptions!

A $75.00 deposit (non-refundable) per camper, per week, is mandatory to hold your camper(s) space. Remaining balance must be paid 14 days prior to the 1st day of the camp week.
How many campers are you registering today? (Maximum campers per registration form is 3)*
Type Number of Campers Here
FacebookGoogle SearchMagazine AdYard SignWord of MouthBillboard
- Camper #1 Full Name*
  
  First NameLast Name
- Age*
- Date of Birth*
- Race*
- Date of Camp Week*
  
  MonthDayYear
  Date
- Week 1 TVWeek 2 SportsWeek 3 RadioAll 3 weeksOvernight Camp
- MaleFemale
- Grade*
- SS#*
  Last 4 digits
- Hair Color*
- Eye Color*
- Weight*
- Height*
- Lunch Opt-Out (Optional)Child with Allergies and or Medical Condition(s)- Lunch Opt-In (a mandatory Meal Wavier must be signed)
- BeginnersIntermediateNone
- TV Broadcasting (On-camera/Production)Radio HostingSport ReportingJournalism
- List other talents and hobbies that your child has*
- Camper #2 Full Name*
  
  First NameLast Name
- Age*
- Date of Birth*
- Race*
- Date of Camp Week*
  
  MonthDayYear
  Date
- Week 1Week 2Week 3All 3 weeksOvernight Camp
- MaleFemale
- Grade*
- SS#*
  Last 4 digits
- Hair Color*
- Eye Color*
- Weight*
- Height*
- Lunch Opt-Out (Optional)Child with Allergies or Medical Condition(s)- Lunch Opt-In (a mandatory Meal Wavier must be signed)
- BeginnersIntermediateNone
- TV Broadcasting (On-camera/Production)Radio HostingSport ReportingJournalism
- List other talents and hobbies that your child has*
- Camper #3 Full Name*
  
  First NameLast Name
- Age*
- Date of Birth*
- Race*
- Date of Camp Week*
  
  MonthDayYear
  Date
- Week 1Week 2Week 3All 3 weeksOvernight Camp
- MaleFemale
- Grade*
- SS#*
- Hair Color*
- Eye Color*
- Weight *
- Height*
- Lunch Opt-Out (Optional)Child with Allergies- Lunch Opt-In (a Meal Wavier must be signed)
- BeginnersIntermediateNone
- TV Broadcasting (On-camera/Production)Radio HostingSport ReportingJournalism
- List other talents and hobbies that your child has*
- Parent Full Name*
  
  First NameLast Name
- Relationship*
- Email Address (Primary)*
  
  Confirmation Email
- Address (Primary)*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Mobile Number*
- Work Number
- * All payments and all deposits are Final and Non-Refundable, No Exceptions! [There will only be a refund if the Camp Host deems it necessary to cancel the entire summer camp season].
  
  * CYBC reserves the right to make any change(s) to the weekly schedule, the weekly camp date(s), and this is not limited to cancelling any week(s) in the event of low enrollment. In the event there is a change of date within scheduled camp week... you (parent/guardian) will need to adjust for the new date.
  
  * In addition, we reserve the right to make any changes to camp location, guest speaker(s), camp menu, and or field trip(s).
  
  Admissions and Accommodations Policy
  Charlotte Youth Broadcasting™ Camp is an equal-opportunity organization and considers all registrations without regard to race, color, religion, sex, or national origin.
  
  Scope of Care & Training Our program is specifically designed for youth broadcasting instruction and is staffed accordingly. While our team is trained in standard CPR and First Aid, we are not a specialized care or medical facility. We are not equipped to provide one-on-one supervision, specialized behavioral intervention, or medical support beyond basic first aid.
  
  Medical & Activity Clearance If a child has any diagnosed medical, emotional, or physical condition that may impact their participation, a formal physician’s note is required. This documentation must explicitly release the child to participate in all camp activities without limitations or specify exactly what accommodations are required for safety. Charlotte Youth Broadcasting™ Camp reserves the right to decline or rescind admission if a child’s needs require a level of attention or specialized training that exceeds our program’s operational scope.
  
  Mandatory Pre-Registration Consultation To ensure a safe and successful experience, parents or guardians must contact the Camp Director to discuss any special circumstances or limitations prior to registration and prior to making any payment. Final enrollment eligibility is determined at the sole discretion of the Camp Director based on our ability to safely accommodate the child's needs.
  
  All campers are to follow all rules of the Charlotte Youth Broadcasting™ Camp. Campers are expected to be respectful of Instructor(s) and other campers, participate in activities, follow instructions, keep their hands to themselves, no foul language, dress appropriately, weapons of any kind are prohibited, and Zero Tolerance for bullying and violence. Furthermore, you give permission for your Child(ren) to be transported to and from the main campsite for off-site field trips in the vehicle(s) manner of which Charlotte Youth Broadcasting™ Camp deems necessary [not limited to hired shuttles, personal vehicles, and or chaperone’s vehicles].
  
  Any physical sign(s) of abuse on a child shall be reported to the proper state and or county authorities without the parent(s) being made privy to CYBC finding(s) report, and or complaint made. Furthermore, if a child verbally states he/she is being [or has been] abused the proper state/county authorities shall be contacted. Furthermore, you agree that you shall not use the teaching, process(es), and or strategies from CYBC to compete by creating a brand, camp, company, and or event similar in whole or in parts to the likeness of Charlotte Youth Broadcasting™ Camp. I agree as a parent or guardian to indemnify and hold harmless Charlotte Youth Broadcasting™ Camp, its owner, subsidiaries, volunteers, interns, chaperones, and or staff in the event of any incident, death, or accident that may occur while in attendance and or while traveling with Charlotte Youth Broadcasting™ Camp.
  
  I fully understand that if my child(ren) is an overnight camper(s) they shall be housed and occupy the same area(s) with other camper(s) of the same sex [original born-gender], and my child(ren) shall be housed and occupy the same area(s) with an adult camp counselor of the same sex. As the parent or guardian of my Child(ren) I grant Charlotte Youth Broadcasting™ Camp my full permission.
  
  I have read this policy in full, I fully understand, and I totally agree that myself and my child(ren) shall comply with all policies and all procedures of Charlotte Youth Broadcasting™ Camp, failure to do so shall result in removal from camp without a refund of any payment(s). It is understood that the camper(s) is enrolled for the entire weekly session(s); no deductions or refunds will be made for you (parent/guardian) cancelling, absences or withdrawal, voluntary or involuntary.
  
  By signing this contract, I am agreeing that my camper(s) and I shall fully adhere to the policy, terms, and or conditions.
- Parent(s) and or Guardian(s) Signature *
  
  Clear
- Signature*
- Media Release and Consent:
  
  I, the undersigned parent or legal guardian, hereby grant Charlotte Youth Broadcasting™ Camp (“CYBC”), its employees, representatives, agents, and authorized third parties, full permission to photograph, film, videotape, record audio, and conduct on-camera interviews with my child(ren) during participation in CYBC programs and activities.
  
  I further authorize my child(ren), during camp hours and under supervision of CYBC staff, to participate in the creation and development of media-related content, including but not limited to social media profiles, websites, blogs, articles, video productions, podcasts, and/or DVDs as part of camp programming.
  
  I grant CYBC the unrestricted and perpetual right to use, reproduce, edit, publish, distribute, display, and otherwise utilize my child(ren)’s name, image, likeness, voice, and recorded statements for promotional, educational, marketing, advertising, or informational purposes. Such use may occur in any medium now known or later developed, including but not limited to television, newspapers, magazines, websites, social media platforms, and other digital or print media.
  
  I understand and agree that these materials may be used by CYBC without further notice or approval. I further acknowledge that no royalties, compensation, or other payment of any kind will be provided to me, my child(ren), or our respective heirs, successors, or assigns for the use of such materials.
  
  By intialing below, I confirm that I am the parent or legal guardian of the child(ren) listed and that I have the authority to grant this permission on their behalf.
- Initials*
- Has your child(ren) or an immediate family member of your child(ren) been diagnosed with COVID-19 (CoronaVirus) or been directly exposed to COVID-19 (CoronaVirus), Monkeypox, Measles or any other contagious virus / disease within the last 30 days?*
- Please type your name*
  
  First NameLast Name
- If you have answered No to the above question, please sign the below box to verify that your response is truthful and accurate based on the best of your knowledge. *
  
  Clear
- Does your child require any specific accommodations or specialized equipment to participate in daily activities?*
- Does your child currently receive one-on-one support or a dedicated paraprofessional during the school year?*
- Are there specific triggers or environmental factors (e.g., loud noises, crowded rooms, high-pressure tasks) that may cause your child distress?*
- Does your child require specialized behavioral intervention or a specific behavior management plan?*
- Will your child require the administration of any medication during camp hours?*
- Has your Child been diagnosed by a doctor with any diagnosed medical, physical, emotional, or mental health conditions?*
- If you have answered yes to the above question, please provide a detailed description in the space below. *
- We would like to thank you for your interest in Charlotte Youth Broadcasting™ Camp. In order to proceed with your child(ren) application, we ask that you provide medical documentation releasing your child to attend this summer's camp. All documentation can be emailed to Charlotteybc@gmail.com, please title the subject line with the following: Your Child's First and Last Name, CYBC Medical Release. The medical release must include the date of exposure, and the primary doctor's note must state that he/she is Free of Corona Virus /COVID-19 /Variants /Monkeypox.
  
  We thank you for your understanding and we look forward to your camper attending this summer's camp.
- Initials*
- In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by an adult leader or adult staff member in charge to hospitalize, secure proper anesthesia, and or to order injection of surgery for my child(ren). Additionally, you give permission for your child(ren) to be treated by an adult CYBC staff member for any minor scrapes, scratches, and or abrasions. You give permission for CYBC to adminsiter any medication(s) that your child(ren) is required to take by a medical doctor.
  
  Any medication to be administered during camp hours, the parent(s) shall provide the following to the CYBC Camp Director:
  - The medicine
  - The dosage (how much)
  - The frequency (how often)
  - The route (how to adminsiter) (excludes rectal administration!)
  - The storage instructions
  This registration form is correct to the best of my knowledge and the child(ren) herein described has my permission to engage in all activities.
- Medical Insurance Policy #*
- Family Physician Name*
- Family Physician Number*
- Please list ALL current/past medical conditions and ALL allergies (incl food allergies). The Parent / Guardian is solely responsible for providng any medication (and the instructions) that must be administered to their child(ren) while at camp.*
  **Any food allergies are an automatic opt-out lunch. Parent MUST provide lunch according to your child(ren) needs**
- I acknowledge that my child(ren) has a food allergy/allergies and or a non-food allergy. Therefore, I fully understand that by choosing to Opt-In for the camp meals, that I shall hold harmless (known as "Indemnify") and covenant not to sue Charlotte Youth Broadcasting™ Camp in the event of any type of reaction/consequences/death as a result of my child(ren) drinking, digesting, and or eating any food or beverage provided by Charlotte Youth Broadcasting™ Camp. *Attention parents of campers with food allergies: Food prepared and provided by CYBC may contain or come in contact with the following ingredients: common allergens, such as dairy, eggs, wheat, soybeans, tree nuts, peanuts, fish, shellfish, gluten, or wheat and this is not limited to different meat variations. Furthermore, by signing this meal waiver form, I fully understand the risk that I am taking by not providing my child(ren) food according to their dietary needs.
- Initial*
- LIST 2 NAMES AND PHONE NUMBERS OF PERSONS TO CONTACT IN CASE OF EMERGENCY IF YOU’RE NOT AVAILABLE. THESE INDIVIDUALS SHOULD BE AUTHORIZED TO PICK UP YOUR CHILD AND MAKE MEDICAL DECISONS.
- Contact #1*
  
  First NameLast Name
- Relationship*
- Same address as Parent/Guardian
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Mobile Number*
- Home Number
- Contact #2*
  
  First NameLast Name
- Relationship*
- Same address as Parent/Guardian
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Mobile Number*
- Home Number
- LIST ANYONE NOT AUTHORIZED TO PICK UP YOUR CHILD
- Full Name (Not Authorized)
  
  First NameLast Name
- Please explain
  (If the person is a legal parent/guardian you must have legal documents from the court stating this person is not allowed to pick up your child.)
- I acknowledge that I have read CYBC policies in full, I completely understand, and fully agree to comply with all above releases, policies, and the procedures of Charlotte Youth Broadcasting™ Camp. The Undersigned, on his or her behalf and on the behalf of his or her child(ren), hereby releases, waives, discharges and covenants me not to sue.
- Parent/Guardian Printed Name*
- Parent/Guardian eSignature*
  
  Clear
- Date Signed
  
  MonthDayYear
  Date
- Should be Empty:

Charlotte Youth Broadcasting™ Camp