Summer FUN Camp APPLICATION
PARTICIPANT INFORMATION
FIRST________________M_______LAST___________________NICKNAME__________
Child’s Name
STREET_________________CITY______________APT.#_____STATE_____ZIP_________
Child’s Address
HOME PHONE(_____)_______________
SEX: male_____ female_____
D.O.B ___/___/___ AGE IN FALL______
PARENT/GUARDIAN INFORMATION
FIRST_________________M_________LAST_____________________________________
Mother’s/Guardian Name
STREET___________________CITY_____________APT.#_____STATE_____ZIP________
Mother’s/Guardian Address
HOME PHONE(_____)________________CELL(___) _________________
OCCUPATION__________________________WORK PHONE(___) ___________________
E-MAIL________________________________
FIRST_________________M_________LAST_____________________________________
Father’s/Guardian Name
STREET___________________CITY_____________APT.#_____STATE_____ZIP________
Father’s/Guardian Address
HOME PHONE(_____)________________CELL(___) _________________
OCCUPATION__________________________WORK PHONE(___) ___________________
E-MAIL________________________________
PARENTS ARE:
___Married ___Living Together ___Divorced ___Separated ___Widowed
___Single
IF DIVORCED/SEPARATED:
Parent/Guardian with legal custody______________________________________________
It is helpful to furnish a copy of the divorce decree or custody agreement which will be kept in your child’s file and all information will be confidential. Without a copy of the official papers, Fun Unleashed may not be able to prevent your child from leaving with his/her
non-custodial parent.
EMERGENCY CONTACT INFORMATION (please list two contacts)
FIRST_________________M_________LAST_____________________________________
1st Contact Name
STREET___________________CITY_____________APT.#_____STATE_____ZIP________
1st Contact Address
HOME PHONE(_____)________________CELL(___) _________________
1st Contact Personal Information
______________________________________________________________________________
FIRST_________________M_________LAST_____________________________________
2nd Contact Name
STREET___________________CITY_____________APT.#_____STATE_____ZIP________
2nd Contact Address
HOME PHONE(_____)________________CELL(___) _________________
2nd Contact Personal Information
_______________________________________________________________
MEDICAL INFORMATION
DOCTOR:_________________________________OFFICE PHONE: (___)______________
Name
STREET:__________________CITY:___________APT.#:____STATE:____ZIP:_________
Office Address
MEDICAL INS. #:___________________CHILD’S PERSOANL ID#:___________________
CHILD’S SOURCE OF DENTAL CARE/DENTIST’S NAME:________________________
DENTIST OFFICE PHONE: (___)___________________
ALLERGIES:____________________________________________
________________________________________________________________________________________________________
MEDICAL PROBLEMS: ______________________________________
________________________________________________________________________________________________________
MEDICATION:___________________________________________
________________________________________________________________________________________________________
ADDITIONAL INFORMATION: PLEASE INDICATE LIKES/ DISLIKES, DIET, SPECIAL INTERESTS, ETC.
IMMUNIZATION:
FUN UNLEASHED REQUIRES THAT WE HAVE A PHOTOCOPY OF YOUR CHILD’S RECENT IMMUNIZATION RECORD IN OUR FILES. PLEASE INCLUDE A PHOTOCOPY WITH THIS REGISTRATION FORM. IF YOU DO NOT HAVE THE RECORDS, A COPY CAN BE OBTAINED FROM YOUR DOCTOR.
EMERGENCY CONSENT:
IT IS OUR POLICY OF TO NOTIFY A PARENT WHEN A CHILD IS ILL OR NEEDS MEDICAL ATTENTION. OCCASINALLY, WE CANNOT CONTACT A PARENT AND WE NEED TO GET IMMEDIATE HELP FOR THE CHILD. OUR PROCEDURE IS TO TAKE THE CHILD TO THE NEAREST EMERGENCY SERVICE.
PLEASE SIGN BELOW SO THAT WE CAN TAKE APPROPRIATE ACTION ON BEHALF OF YOUR CHILD
I HAVE PROVIDED INFORMATION ON MY CHILD’S SPECIAL NEEDS (ALLERGIES, DIET, DISABILITIES, AND/OR MEDICAL INFORMATION) TO THE PROVIDER, AS MAY BE NECESSARY TO ASSIST THE FACILITY IN PROPERTY CARING OF MY CHILD IN CASE OF AN EMERGENCY.
YES________ NO________
I AGREE TO REVIEW AND UPDATE THIS INFORMATION WHENEVER A CHANGE OCCURS AND AT LEAST ONCE EVERY SIX MONTHS.
YES________ NO________
I HEREBY GIVE MY/OUR CONSENT FOR MY/OUR CHILD_______________________
WHEN ILL/INJURED, TO BE TAKEN TO THE NEAREST EMERGENCY CENTER BY THE STAFF OF MY CHILD’S DAYCARE WHEN I/WE CANNOT BE CONTACTED. I CONSENT TO AN AMBULANCE BEING CALLED TO TRANSPORT THE CHILD, IF NECESSARY. I FURTHER AGREE TO PAY ALL COSTS INCURRED FOR TRANSPORT.
PLEASE READ AND SIGN
WAIVER
I hereby grant permission for my child to be transported by Fun Unleashed for activities and field trips. In case of medical emergency, I understand that every effort will be made to contact me or my emergency contact. If I or someone on my emergency form cannot be reached, I give Fun Unleashed permission to secure the medical treatment necessary for my child; including hospitalization, injection, anesthesia, or surgery.
Further authorization is given to the Camp Director or their designee to provide over the counter medication to this child as necessary.
I understand that Fun Unleashed assumes no responsibility for injuries or illnesses which my child may sustain as a result of his/her physical condition or resulting from his/her participation in any athletic activities, sports program, the use of equipment, exercise or other activities. I expressly acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illness which may result from his/her participation in these activities and I hereby release and discharge Fun Unleashed, its agents, servants, and employees from any and all claims for injury, illness, death, loss or damages which he/she may suffer as a result of his/her participation in these activities. I understand that Fun Unleashed in not responsible for personal property lost or stolen while members and/or program participants are using Fun Unleashed facilities or on Fun Unleashed property. This disclaimer also extends to the facilities used in the commission of the child care program. I acknowledge the waiver and accept the conditions set forth above. I agree to adhere and abide by the policies.
_____________________________________________ __________________________
Parent/Guardian Signature Date
_____________________________________________ __________________________
Parent/Guardian Signature Date
SCHEDULING DATES (2010) minimum 1 week
Week of June 7th to Labor Day Weekend
HOW DID YOU FIND OUT ABOUT THE FUN UNLEASHED SUMMER FUN CAMP?
REFERRAL_____ SCHOOL_____ FRIEND_____ SUMMER CAMP FAIR____
WEBSITE_____ VISIT LOCATION_____ NEWSPAPER AD_____
OTHER_____________________________________________________