CampRegistration

Tech-Futures Summer Camp Registration Form

Summer Camper Info:

Name

Age

Date of Birth

Gender:

Male

Female

Prefer not to say

Parent or Legal Guardian's Info:

First Name

Last Name

Phone

Relationship to Child

Street

City

Zip

Country

Are there any activity restrictions for your child?

Yes

If you selected yes, please describe activity restriction below:

Medical and Health Information

Does your child have any of the following conditions

Asthma

Diabetes

Seizures

Other

If you selected other, please describe:

Does your child have any allergies, If yes, please describe below:

Does your child take any medications? if yes, please describe below:

Primary Physician Name

Phone Number

Health Insurance Provider:

Policy Number

EMERGENCY CONTACT INFO (Must be different than parent listed above)

Emergency Contact # 1

Last Name

Relationship to Your Child

Phone

Emergency Contact # 2

Last Name

Relationship to Your Child

Phone

Emergency Contact # 3

Last Name

Phone

Authorized Pick-Up List (Only these individuals may pick up your child from camp)

Permissions

I give permission for my child to participate in all camp activities.

I authorize the camp staff to seek emergency medical treatment if I cannot be reached.

I grant permission for my child to be photographed or video recorded for camp marketing or educational purposes.

I have read and agree to the camp’s liability waiver and policies.

T-Shirt Size

Submit

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