Clone of radKIDS Camp Detailed Registration Form

radKIDS: Safety Empowerment Camp

July 27th- July 31st Registration confirms your child’s commitment to attend all scheduled camp days, as each session builds upon the previous one for full program impact.
Athlete Information
radKIDS Name

First NameLast Name
Birth Date

MonthDayYear
How old will your child be at the time of camp?
Camp sessions are based on age at the start of camp:5–6: 8–10 AM | 7–9: 11–1 PM | 10–12: 2–4 PM
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Why We Collect Medical & Emergency Information
Your child’s safety is our highest priority. The information you provide on this form allows the Nassau County Coalition for Community Health and the radKIDS® program to prepare for and respond appropriately to any medical needs, allergies, or special accommodations that may arise during camp.

This information will be used only by program instructors and authorized staff/volunteers to ensure your child’s well-being. It will not be shared outside of the Nassau County Coalition for Community Health or radKIDS®.
Date of most recent medical examination
Has your child or anyone in your child's household been confirmed as COVID positive or with COVID antibodies?
Does your child feel fine, without restriction? If no, please describe.
YesNo, Please Describe
NoYes, Please Describe
NoYes, Please Describe
Has your child ever been hospitalized or treated for an injury? If yes, please describe.
NoYes, Please Describe
Has your child ever been injured and not received medical attention? If yes, please describe.
NoYes, Please Describe
Does your child have any current medical conditions for which they are currently being treated? If yes, please describe.
NoYes, Please Describe
Is your child currently using any prescription medications? If yes, please describe and share if you feel it will affect their safe participation.
NoYes, Please Describe
Does your child need any special medical support or accommodations in class? If so, please describe.
YesNo
YesNo
YesNo
Does your child have any known allergies? If yes, please describe.
NoYes, Please Describe
Low/LimitedModerate/AverageAbove Average
Please describe any exercise, activities, or athletic participation your child currently engages in, if any.
Is your child now, or have they ever, been involved in self-defense or martial arts training? If yes, please describe.
By clicking “Submit,” I acknowledge and agree to the following on behalf of my child:

I understand the physical nature of the radKIDS® program and the potential risks of injury associated with participating in a practical course involving self-defense and personal safety techniques. I confirm that my child is physically able to participate in activities that may include various physical movements and drills. I understand that these techniques cannot be successfully applied in every situation and that proficiency requires continued practice, good judgment, and individual ability.

I acknowledge that sensitive topics may be discussed during the program and are available for review in the Parent Manual.

COVID-19 Awareness: I understand that participation in this program involves inherent risk of exposure to COVID-19 or other illnesses in a public setting. By allowing my child to participate, I voluntarily assume all risks related to such exposure.

I agree to release and hold harmless radKIDS®, Inc., its certified instructors, program staff, volunteers, and any associated partners or sponsors from any liability for injury that may occur as a result of participation in this program or the use of techniques learned.

I understand that the information provided in this registration form will be transferred to official radKIDS® required documentation, which will be reviewed and signed in person at check-in prior to participation.

By submitting this form, I confirm that I have read, understand, and voluntarily agree to the above terms.
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radKIDS: Safety Empowerment Camp

Athlete Information