1.By checking this box, I state that I am legally authorized to register this child for Camp FUN.

Yes

No

2.FIRST Name of Child

3.LAST Name of Child

4.PREFERRED Name of Child

5.Age of Child at time of camp

6.Gender of Child

7.Please list any facts concerning the child's medical history, including any physical or emotional challenges, that are important for Camp FUN Staff to know.

8.Does the child have any food allergies/sensitivities?

9.If YES (food allergies/sensitivities), please explain. (What foods? What are the typical symptoms of a reaction? Are medications necessary in the event of a reaction?)

10.Does your child have any medications for emergency situations (e.g. EpiPen)? If YES, please bring the medication to Camp FUN, clearly marked with the child's name.

11.Does your child require medication administration during camp hours (e.g. insulin)? If YES, please bring the medication to Camp FUN, clearly marked with the child's name and instructions.

12.Please use this space to provide any other information that is important for us to know about your child's physical, emotional and/or mental health.

13.What is your relationship to the child?

14.If OTHER/RELATIVE, please explain your relationship to the child.

15.YOUR Contact Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email address

Phone Number

16.Does the child live at the same address as you?

17.If the child lives at a different location than you, please provide the contact information below.

18.Will the child need TRANSPORTATION to Camp FUN? (If Yes, you will be contact to make arrangements for transportation.)

Yes

No

19.Is there anyone who CANNOT pick up the child from Camp FUN? Please list the names below.

20.In the event of an emergency and we are unable to contact you, please provide at least one (1) other person we can contact. Please include the NAME and PHONE NUMBER of the contact.

21.PHOTOGRAPHY RELEASE: We plan on having polaroid cameras on site so the kids can take pictures of each other and take home if they have permission. We will not be taking photos for any other reason or use any photos publicly. We also only do this when 100% of attendees have permission. If permission is granted, please type name and date. Otherwise, state "NO.")