CAMP REGISTRATION CHILD PERSONAL INFORMATION Child’s Full Name: Child’s Date of Birth (mm/dd/yyyy): Home address: Gender: FemaleMale Days of childcare required (select all that apply): MondayTuesdayWednesdayThursdayFriday Hours of childcare required: Full dayHalf day (morning)Half day (afternoon)Other Please provide any additional information about the child that may be useful (ex. Do they have siblings, do they enjoy particular games, should we be aware of any stressors, etc): CHILD MEDICAL INFORMATION Please list any known allergies, including medication allergies, or existing medical conditions: Please list any medications that the child needs to receive while in the childcare facility. Include name of medication, dosage, and instructions on the time and method of administration: Please list any special accommodations and accessibility needs for child due to medical conditions: Name of child’s primary care physician: Contact number of child’s primary care physician: Preferred hospital in case of emergency: Insurance / health coverage information: PARENT PERSONAL INFORMATION Note: please list the information for both parents / legal guardians when applicable. Please list the details of the parent / legal guardian that you wish to be the primary contact first on the form. Name of parent: Address of parent: Contact number: Contact email: Place of work: If applicable: Name of parent: (if different) Address of parent (if different): Contact number: Contact email: Place of work: EMERGENCY CONTACT & AUTHORIZED FOR PICK-UP: Note: please list the details of an emergency contact, in case the parent(s) listed above cannot be reached in an emergency. All authorized to pick up your child must provide proof of identification at the time of pick-up. Name of Emergency Contact: Address of Emergency Contact: Emergency Contact number: Emergency Contact email: Place of work (Emergency): Relationship to the child: Note: if there is an additional individual who you wish to authorize, in addition to parents listed above and the emergency contact, to be able to pick up the child from the childcare facility, please include their information below. Please note: all authorized to pick up your child will need to provide proof of identification at the time of pick-up. Name of Authorized Person: Address of Authorized Person: Contact number of Authorized Person: Contact email of Authorized Person: Place of work of Authorized Person: Authorized Person Relationship to the child: I have read this form and certify that I understand its contents, and the information provided is accurate. I acknowledge that I am responsible for all reasonable charges in connection with care and treatment rendered during this period. I will notify the childcare facility in writing in case any of the information in this form changes. Date of form submission: Parent or authorized legal representative full name: Submit
