Poor People’s Economic Human Rights Campaign Summer Camp Registration Form

camp

Please complete this form and send it to  Cheri Honkala at cherihonkalappehrc@gmail.com.  Please be sure to indicate “registration” in the subject heading so we can keep track of your application.

You can download a copy to your computer by clicking the hyperlink, or use the text embedded below.

SUMMER CAMP REGISTRATION FORM

One form per participant is required. Both sides must be filled out completely in order to process your registration.

PLEASE PRINT CLEARLY

Camper’s

First Name:____________________________________________________

Last Name:____________________________________________________

Address:______________________________________________________

City:_________________________________________________________

State: ________________________________________________________

Zip:__________________________________________________________

Home Phone:___________________________________________________

Parent/Guardian’s email:___________________________________________

Camper’s Birthday:______/______/______ Grade:_______________________

School:________________________________________________________

Are there any activities in which she/he should not participate?

______________________________________________________________________________

Does your child have any special physical, behavioral and/or needs our staff should be aware of? Please explain

_______________________________________________________________________________

 

Parent/Guardian Information

Name:________________________________________________________

Work Phone: ___________________________________________________

Cell:_________________________________________________________

Name:________________________________________________________

Work Phone:____________________________________________________

Cell:__________________________________________________________

Are there any custody concerns that we should be aware of? ___________________________________

 

Emergency Contact / Child Release Authorization

PPEHRC has my unrestricted permission to release the named minor at any time, to the following individuals, and to contact them in case of an emergency if the parents / guardians are unavailable.

Name:________________________________________________________

Phone#:___________________Relationship:__________________________

Name:________________________________________________________

Phone#:___________________Relationship:___________________________

Name:________________________________________________________

Phone#:___________________Relationship:__________________________

 

Health Information

To be completed by parent/guardian.

 

Name of Physician:_______________________________________________

Phone #: ______________________________________________________

Name of Dentist :________________________________________________

Phone #: ______________________________________________________

Carrier of family medical/hospital insurance and policy#:

_____________________________________________________________

_____________________________________________________________

Health History

(Check all that apply, giving approximate dates)

Diseases

Chicken Pox ____________________________________________________

Measles _______________________________________________________

German Measles ________________________________________________

Mumps _______________________________________________________

Ear Infections ___________________________________________________

Heart Defect/Disease ______________________________________________

Contact Lenses/Glasses ____________________________________________

Epilepsy _______________________________________________________

Diabetes _______________________________________________________

Asthma ________________________________________________________

Bleeding Disorder ________________________­_________________________

Other __________________________________________________________

Does your child have any allergies? (Please list)

_______________________________________________________________

_______________________________________________________________

Parental/Guardian Consent

Recognizing that the PPEHRC camp will do its best to ensure a safe experience, I understand that certain dangers or accidents may occur. I hereby release camp from any and all responsibility and liability of any nature, including claims of injury, illness, death, loss or damage, resulting from my child’s participation in any program activities.

 

Participation Agreement

Please go over these items with your child:

1. Participant agrees to abide by rules and regulations set by the program for the health, safety and welfare of the participants.

2. Willful destruction of property will be the responsibility of the participant’s parent/guardian.

3. Participants are not allowed to be in possession of any tobacco, alcohol, illegal drugs, firecrackers, firearms, or knives.

4. The PPEHRC is not responsible for lost, damaged or stolen personal belongings.

5. Continued inappropriate behavior, such as threatening, swearing, not following directions, teasing, sexual harassment/intimidation, fights, or improper behavior in vehicles, may result in immediate dismissal from the program.

6. Any participant who poses a threat to themselves or to others will be dismissed from the program.

The Camp Director reserves the right to determine what constitutes a violation of these rules and will enforce them as necessary. We reserve the right to dismiss any participant from the program at the parent/guardian’s expense and liability for violating any of the above.

By Signing Below, I Agree That:

✓ I have read and understand the parent/guardian consent.

✓ The named minor has my permission to participate in PPEHRC programs and field trips.

 

____________________________________________________________________

Signature of Parent/Guardian                           Printed Name           Date


 

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