Summer Camp Application | Jackson County Civic Action Commitee

Today's Date*

Child's Name*

First Last

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mother's Name*

First Last

Telephone Number*

Mother's Place of Employment

Telephone Number

Father's Name

First Last

Telephone Phone

Father's Place of Employment

Telephone Phone

Emergency Contacts (if parent cannot be reached)

Emergency Contact*

First Last

Phone*

Emergency Contact*

First Last

Phone*

I have been informed that this center does provide liability insurance for my child.*

Yes
No

Please list any allergies your child may have, including food:*

If no allergies, please enter N/A

My child may be photographed and/or videotaped at this facility:*

Yes
No

My child may take approved field trips sponsored by this facility:*

Yes
No

This center may give my child emergency medical treatment if needed:*

Yes
No

Person(s) Allowed to pick up my child(ren

Name

First Last

Telephone Number

Name

First Last

Telephone Number

Name

First Last

Telephone Number

Authorization*

I agree to adhere to all Policies and Procedures set forth by Jackson County Civic Action.

Electronic Signature*

I certify that the above information provided is true and correct to the best of my knowledge.

Name*

First Last

Date*

Summer Camp Registration Form

Summer Camp Registration Form

Summer Camp Registration Form

Emergency Contacts (if parent cannot be reached)

Person(s) Allowed to pick up my child(ren