SUMMER CAMP 2024

First Name

Last Name

Age

Birth Date

Grade

Name of School Attending

Has the child attended summer camp before?
YesNo

Does the child require any special accommodations?
YesNo

If yes, please explain (optional)

What is the child’s learning style/How does your child learn best?
VisualAuditory (hearing)Tactile (touch)Kinesthetic (doing and moving)Reading and writingOther

Other

First Name

Last Name

Home Phone (optional)

Cell Phone

Email

Address

City

Zip

Place of Work

Work Phone

First Name

Last Name

Home Phone (optional)

Cell Phone

Email

Address

City

Zip

Place of Work

Work Phone

First Name

Last Name

Relationship

Home Phone

Cell Phone

Name and phone number(s) of person(s) other than yourself allowed to pick up your child.

First Name

Last Name

Phone

First Name

Last Name

Phone

Child’s Medical Information Form

The medical background of each camper is required as part of the camp’s registration process. The camp program director must be advised in writing of any condition that would limit the camper’s ability to participate in any program.

Pediatrician's Name

Phone

Date of Last Visit

Date of Last Tetanus Shot

Medical Conditions

List all medications being taken (prescription and over the counter):

*It is requested that parents/guardians administer any medication to the child before arriving to the Program. Program Staff will not administer any medication to a child.

Allergies
Yes (list below)No

List Allergies (optional)

Does your child require an Epi-Pen? If yes, you must provide the camp with an Epi-Pen on the child’s first day at the camp. The Epi-Pen will be kept at the camp during your child’s enrollment.
YesNo

List any specific activities to be restricted for health reasons

ACKNOWLEDGEMENT/PERMISSION

The Brookland-Lakeview 21st Century COLA Program does not discriminate on the basis of race, color, sex, handicap, religion or national origin.

I understand and accept these guidelines.

For the Summer Camp, transportation will not be provided by the Brookland-Lakeview 21st Century COLA Program to and from my child’s home. Bus transportation is provided for field trips only. Parents will drop-off and pick up their children.

I give Brookland-Lakeview 21st Century COLA Program permission to photograph and/or videotape my child for public relations and/or marketing purposes. Photos will remain archived at the Brookland-Lakeview 21st Century COLA Program’s office and can be used for promotional purposes without notification.

I give Brookland-Lakeview 21st Century COLA Program permission to transport my child off camp property for the purpose of field trips and/or medical care. I understand that a schedule of events will be available to me and that all events are subject to change due to weather and/or scheduling conflicts without notice.

I authorize the Brookland-Lakeview 21st Century COLA Program Management to act as the agent of the parents in an emergency or to administer basic first aid for the health and welfare of the camper involved. I am responsible for the expenses involved if the services of a physician or hospital are required. Please request a waiver for person requesting exemption from medical treatment.

Preferred Hosptial

By typing your name below, you agree to adhere to all Policies and Procedures set by the Brookland-Lakeview 21st Century COLA Program.

Type your first and last name

Authorization and Waiver to Transport Child

My child requires a booster seat: (all children under 8 years of age are required to be in a booster seat
YesNo

I authorize Brookland-Lakeview Empowerment Center to transport my minor child in a car, van or bus driven by an individual authorized by Brookland-Lakeview Empowerment Center. I understand my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer. I understand participation in the identified event is not a requirement for participation in the program.

I have read, understand, and discussed with my child:

1. My child will travel in a motor vehicle driven by an adult and my child is to wear their safety belt during travel;

2. My child is expected to listen to supervising staff/driver, respect staff and other children, the vehicles they ride in, and the other people they travel with during the trip;

3. Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and

4. My child is to remain in their seat and not be disruptive to the driver of the vehicle.

Select Each Statement To Agree
I recognize participation in this activity as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify I have been advised of the potential risks, and I have full knowledge of the risks involved in this activity, and I assume any expenses incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.
As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Brookland-Lakeview Empowerment Center and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation.
I have read this entire waiver and authorization form, I fully understand its terms and conditions, and I agree to be legally bound by its terms.