Printable PDF version of the form available here: Spring Break camp 2018 Spring Break Camp 2018* Week 1 March 19th - 23rd Week 2 March 26th - 29th Week 3 April 3rd Child’s InformationChild's Full Name*Gender*MaleFemaleBirth Date* Medical NumberFamily Doctor’s NameDoctor's Phone NumberCurrent Swimming LevelAllergiesParent/Guardian and Emergency Contact Information The first parent/guardian listed below will be the primary contact for billing and communication purposes.Parent/Guardian*Home Address (Line 1)*Home Address (Line 2)CityHome Phone #*Cell Phone #Work Phone #Email Address Second parent/guardian infoParent/GuardianHome Address (Line 1)Home Address (Line 2)CityHome Phone #Cell Phone #Work Phone #Email Address If you have custody orders you must attach documentation and inform Supervisors at time of registration.Accepted file types: jpg, png, pdf.Provide three local emergency contacts:Name (1)Relationship to child (1)Home Phone # (1)Cell Phone # (1)Name (2)Relationship to child (2)Home Phone # (2)Cell Phone # (2)Name (3)Relationship to child (3)Home Phone # (3)Cell Phone # (3)I understand the camp runs from 8:00am to 5:30pm. The charge for late pick-up is $10.00 for every quarter hour or portion thereof.* I agree I hereby give my consent for a staff member to administer first aid to my child in the case of accident or illness. Furthermore I give my consent for staff to call a medical practitioner or ambulance. Any expenses incurred in such an event are solely my responsibility.* I agree I hereby give my consent for my child to go on field trips via walking, public transportation or rental bus. I understand that every precaution and safety measure will be taken and waive any liability to the SJD OSC and program staff.* I agree I understand that I am eligible for 75% refund if I provide 2 weeks’ notice before my camp start date.* I agree This iframe contains the logic required to handle Ajax powered Gravity Forms.
