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
How did you hear about CYBC?*

FacebookGoogle SearchMagazine AdYard SignWord of MouthBillboard

Parent/Guardian Information
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*

Area CodePhone Number
Work Number

Area CodePhone Number

Policy Agreement
* 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).

The Charlotte Youth Broadcasting™ Camp considers all registrations without regard to race, color, religion, sex, or national origin. However, the Charlotte Youth Broadcasting™ Camp does reserve the right to refuse admission to any child(ren) that has special emotional, mental, and or physical needs that may require a level of attention that is unreasonable or beyond that which Charlotte Youth Broadcasting™ Camp is designed to accommodate or may require specialized training that may prevent the Charlotte Youth Broadcasting™ Camp staff from adequately meeting the needs of the child(ren). Some activities make it difficult to provide efficient care to some emotionally, mentally, and or physically challenged campers. The parent/guardian must contact the Camp Director prior to registration and prior to making a payment regarding any special emotional, mental and or special physical circumstances or any limitations that your child(ren) may have, so that enrollment can be determined by the Camp Director.

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 initialing and or signing this contract, I am agreeing to fully adhere to the policy, terms, and or conditions.
Initials*

Media Release
I give my full permission for photographs, video footage, audio recordings and on-camera interviews to be conducted with my and by my child(ren) for CYBC and any other third parties that CYBC allows. I give permission for my child(ren) during camp hours to create a social media profile (not limited to a website, Blog, articles, and or, DVD). My child(ren) image(s) and or likeness may be exclusively used for an indefinite time for promotional purposes on television, newspapers, magazines or any other digital/print media deemed necessary by Charlotte Youth Broadcasting™ Camp. It is fully understood, there are no royalties or compensation in any amount that are owed to me, nor my child(ren), nor any of my heirs.
Initials*

Medical Release
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, 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 based on the best of your knowledge. *

Clear
Has your Child been diagnosed by a doctor with any medical and or mental condition(s)?*
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*

Area CodePhone 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**

Food Allergies Opt-In Waiver
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*

Emergency Contact Information
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*

Area CodePhone Number
Home Number

Area CodePhone Number
Contact #2*

First NameLast Name
Relationship*
Same address as Parent/Guardian
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Number*

Area CodePhone Number
Home Number

Area CodePhone 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: