TeamCJColas Youth Summer Registration Form

Youth Summer Program- Registration June 16th-27th
Camper's Information
Last Name*
First Name*
Middle Name*
Gender*

MaleFemale
Youth's Information
Address*
City*
State*
Zip*
Home Phone*

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

Area CodePhone Number
Emergency Number #2

Area CodePhone Number
Birth Date*

MonthDayYear
Year of Graduation*
Grade entering in the fall*
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Cell Phone

Area CodePhone Number
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
Email Confirmation
Parents Email
Second Email
Other Information
How did you hear about The Program?
First Time At Youth Program?*

YesNo
Health Information
It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please see the health officer at that time. Please bring all medication in ORGIANAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.
Is Youth free from infectious desease or conditions?*

YesNo
Are immunications up to date?*

YesNo
Date of last tetanus shot*
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
Any physical, mental or other condition that would require special attention or medication while at camp?*
List any past medical treatment that would be helpful for us to know.*
List any allergies (ex: bees,peanuts, dairy)*
Any dietary needs that we should know about?*
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.*
Youth Release
Youth Release (List anyone, including parents, to whom your camper can be released)*
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named Youth, 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 camper by authorized personnel. The Youth carries secondary insurance. I understand that the above named Youth 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 Youth Program and participate in all activites. I authorize The Springs to use my Youth's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the program.
Signature*

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Youth Summer Program- Registration June 16th-27th

Camper's Information

Youth's Information

Parent or Legal Guardian Information

Parent or Legal Guardian Information

Email Confirmation

Other Information

Health Information

Youth Release