Application Form

Spring Break Camp

    Parent/Guardian 1 Contact Information

    Parent/Guardian 2 Contact Information

    Emergency Contact Information

    Child Health Information

     

    Please indicate and comment on the following health areas and provide any additional special instructions for the provision of care for your child

    Medications:

    Is your child immunized against communicable illness?

    In Case of Illness or Injury
    I hereby give permission for the center staff or their representative to call an ambulance for transportation to the nearest hospital if needed. I understand that all costs incurred are the responsibility of the parent /guardian.

    Parent/Guardian Signature Date