Summer Camp Application Form

SUMMER CAMP APPLICATION FORM

Thank you for printing eligibly or typing. Please fill out this form, one for each student for whom you are applying.
PRIMARY CONTACT INFORMATION
Student's Full Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Start of Attendance*

DayMonthYear
start date
MOTHER's Full Name

First NameLast/Family name
E-mail address: *
example@example.com
Phone number:*
FATHER's Full Name*

First NameLast Name
E-mail address: *
example@example.com
Phone number:*

EMERGENCY CONTACTS

Please provide two additional people, different from the parent listed above, who would automatically be the first person we contact.
First Contact:
Full name:

First NameLast Name
Relationship / contact number:
Second Contact:
Full name:

First NameLast Name
Relationship / contact number:

HEALTH AND SAFETY INFORMATION

please list below all known conditions so we can accommodate your child's needs.
Does your child have ay medical conditions, allergies, or special needs the staff should know about?*

NoYes
If Yes, please describe them below:
PHOTO/VIDEO PERMISSION

CHIPS has my permission to use photographs of my child in the school newsletter, website and school's facebook and instagram page. Your child's name will not be linked to the photos.
YesNo
FIELD TRIP PERMISSION

During Summer Camp, students weekly are taken on field trips. Some of them are in the local area and others are outside the community. When the students go on trips outside the community, they are transported by busses hired by the school. Parents will be notified in advance by their child's teacher of the specific field trip to be taken.
I, do give permissionI, do NOT give permission
I verify that all the information I have provided in this document is true to the best of my knowledge.
Date

DayMonthYear
Date
Signature

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Child's birth certificate

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Parent's ID

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Physician Statement

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Should be Empty:

SUMMER CAMP APPLICATION FORM