Life Camp Student Application 2024-2025

Life Camp Student Application
2024-2025 School Year

View our Information Privacy Policy

Student Information

First Name*

Middle Name*

Last Name*

Nickname*

Date of Birth*

Date

Sex*

MaleFemale

Emergency Contact Name*

Emergency Phone #*

School*

Main Teacher*

Does your child have an individualized education plan (IEP)? If so, what do we need to know?*

YesNo

If yes, what instructions are on the IEP?

Has the student received any of the following disciplinary actions (major referral. suspension, or expulsion) at a previous school, daycare or afterschool program?*

YesNo

If yes, please list each school disciplinary action and an explanation of what happened.

Medical Information

List Allergies

Does your child have anaphylaxis risk factors? (EpiPen required)?*

YesNo

If Yes, Please explain:

Current Medications (List each with prescribed levels & doses and what the medicine treats)

Does your child have any of conditions below? Answer each question with a yes or no. If answer is yes, please explain.

Asthma?*

YesNo

If Yes, Please explain:

Diabetes*

YesNo

If Yes, Please explain:

Seizures?*

YesNo

If Yes, Please explain:

Eye or Ear Issues?*

YesNo

If Yes, Please explain:

Physical Limitations?*

YesNo

If Yes, Please explain:

Any other thing we should know about?

Home Life Information

Name(s) of Legal Guardian(s) (first middle last)*

Home 1 (Primary Residence)

Name(s) of Parent(s) (first middle last)*

Best Phone*

Second Phone*

Best Email*

example@example.com

Second Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List names of all members of this household and their relationship to the applicant*

Home 2 (Second Parent/Guardian)

Name(s) of Parent(s) (first middle last)

Best Phone

Second Phone

Best Email

example@example.com

Second Email

example@example.com

Address (second Parent/Guardian)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List names of all members of this household and their relationship to the applicant

Anything else we should know about your child's home life?

Parent/Guardian Agreement

Parent/Guardian Agreement Page Life Camp, as a ministry of Berkeley Baptist Church, wants to partner with you and your family. By signing the statements below, you indicate your agreement with these necessary policies and statements explaining our partnership.

Designated Pick-up List

To pick-up a child from Life Camp, the person's name must be on this list, the person must be at least 18 years old, and the person must present a valid I.D. at time of pick-up (no exceptions Please name the individuals who may pick-up your child and authenticate it with signature/date.

List Names*

Signature - Pickup List*

Date*

Date

Life Camp Participation

- I hereby affirm that I have read the Life Camp Parent Handbook and discussed its policies with my child. I certify that I consent to and will submit to all the policies in the handbook.
- I understand that Life Camp is a partnership entered into by mutual consent and that either I or Life Camp can end the partnership at any time.
- I agree that campers must cooperate with and follow the directives of the Life Camp staff.
- I affirm that all information in this application is correct, complete, and honestly presented.

Signature - Life Camp Participation*

Date*

Date

Media Agreement

Life Camp may use pictures and videos of my child in its media and publicity programs.

Signature - Media Agreement

Date

Physical Activities & Medical Care Agreement

- I understand that my child will be playing games and doing physical activities as part of the Life Camp program.
- I understand that Life Camp does not provide medical insurance for students.
- I agree that Life Camp staff/ volunteers may need to transport my child to a healthcare facility in the event of an emergency. Life Camp will call me (and other guardians if I am unavailable I agree that I am responsible (and not Life Camp) for any and all medical or health-related cost that might develop as a result of accidents, injury, sickness, or other situations requiring medical

Signature - Medical Care*

Date*

Date