CAMP FITNESS APPLICATION

*How did you hear about our program
If Other, Specify below
*Child First Name
*Child Last Name
*Sex
*Date of Birth (mm/dd/yyyy)
*Age
*Grade
*Child's Last 4 of SSN
School ID
*School Attending
*Home Street Address
*City
*State
*Zipcode

Medical Information

Allergies
Medications
Special Medical Needs
Pertinent Medical History Information
Any other information critical to the child’s well-being; or pertinent information regarding growth and development of the child:

Primary Parent / Guardian Information

*Parent Name (First and Last)
*Relationship To Child
*Home Address
*City
*State
*Zipcode
*E-mail Address
*Home Phone
Mobile Phone
Work Phone
Work Hours

Secondary Parent / Guardian Information

Name (First and Last)
Relationship to Child
Home Address
City
State
Zipcode
Email Address
Home Phone
Mobile Phone
Work PHone
Work Hours

PERMISSION FOR MEDICAL TREATMENT

.I understand that every effort will be made to contact me in the event of any emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize CAMP FITNESS SUMMER CAMP to transport my child to the nearest hospital or medical facility and to secure my child the necessary medical treatments. I understand the employees are trained in the basics of First Aid/CPR and I authorize them to give my child First Aid and or CPR if necessary.

*Child's Name
*Age
*School Name
Physician's Name
Physician's Phone
Insurance Provider
Insurance Policy Number
Please list any allergies, medical conditions, physical limitations, regular medication:
*Parent / Guardian Signature
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PERMISSION FOR FIELD TRIPS

Field trips may be scheduled from time to time throughout the summer camp. We will plan trips in advance and will send home with your child a letter describing the field trip. We will always have adequate supervision and follow established safety guidelines on all trips.

*Select One Below
*Parent / Guardian Signature
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PERMISSION FOR PHOTOGRAPHS AND RESEARCH

Pictures and photos are taken of activities from time to time for the purpose of CAMP FITNESS advertisement, newsletter or other publications. Any children pictured in these publications will not be identified by name. Please sign below your preference for your child to participate.

*Select One Below

From time to time we are asked to allow research to be conducted at our programs by universities or school systems: research will only be allowed by representatives of organizations with proper identification and credentials. Children who participate will not be identified in any research publication, nor will they be allowed to be removed from the program premises by the researcher. Please indicate your willingness for your child to participate.

*Select One Below
*Parent / Guardian Signature
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AUTHORIZED PICKUPS AND EMERGENCY CONTACTS

Permission is given to the following individuals to be released from the program as stated below and / or I give permission for the following individuals to receive my child(ren) at the end of the day.  If parent or guardian cannot be located promptly for emergencies, please indicate your preferred emergency contacts below.

1.  *Name (First and Last)
*Authorized For
*Relationship to Child
Address
*Home Phone
*Other Phone
2.  Name
Authorized For
Relationship to Child
Address
Home Phone
Other Phone
3. Name
Authorized For
Relationship to Child
Address
Home Phone
Other Phone
4.  Name
Authorized For
Relationship to Child
Address
Home Phone
Other Phone

* Parent / Guardian Signature
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WAIVER OF LIABILITY

I understand that even when every reasonable precaution is taken, accidents can still sometimes happen. Therefore, in exchange for me and or my children being allowed to participate in the camp activities, I release CAMP FITNESS SUMMER CAMP and A LIFE FOR A LIFE INTERNATIONAL from ALL liabilities, injuries, losses or damages connected in any way whatsoever to me or my child’s/children’s participation in activities on or off the premises. I understand that this release includes directors, administrators, staff and guest. I have read, understand and I voluntarily sign this authorization and release.

*Parent / Guardian Signature
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