Registration Form – I.N.S.P.I.R.E. Summer Camp

Participant
Information of the child who will participate in the summer camp.
Child's Name *
First
Middle
Last
Child's Birth Date *
Age *
Grade Completed *
Gender *
Male Female
Medical Information
Medical information about your child
Does your child has any allergies, chronic illness, or medical conditions? If yes, please describe.
Parent / Legal Guardian Contact Information
Legally Responsible Party for the Child
Parent/Guardian Name #1 *
First
Last
Cell Phone Number *
Work Phone
Email Address *
Address *

Address Line 1 *

City *

State *

Zip Code *

Country *
Parent/Guardian Name #2
First
Last
Cell Phone Number
Work Phone
Email Address
Address

Address Line 1 *

City *

State *

Zip Code *

Country *
Emergency Contact Information
Person to contact in case of an emergency
Emergency Contact Name *
First
Last
Emergency Contact Cell Phone Number *
Emergency Conctact Address *

Address Line 1 *

City *

State *

Zip Code *

Country *
Informed Consent and Acknowledgment
I hereby approve my child’s participation in all activities organized by INSPIRE Summer Camp by Andelige Trauma Counseling & Consulting, PLLC . By enrolling my child, I accept all risks and hazards incidental to the camp activities, and I release, absolve, and hold harmless INSPIRE Summer Camp by Andelige Trauma Counseling & Consulting, PLLC and all its officers, agents, and representatives from any liability for injuries to my child arising from participating in, traveling to, or returning from the camp sessions.In the event of an injury to my child, I waive all claims against INSPIRE Summer Camp by Andelige, including all staff and affiliates, participants, sponsors, and advertisers, as well as, if applicable, the owners and lessors of the premises used for the activities.
Medical Release and Authorization
As the parent or guardian of the named child, I authorize a qualified and licensed medical professional to diagnose and treat the minor child in the event of a medical emergency. This authorization applies when, in the opinion of the attending medical professional, immediate medical attention is necessary to prevent further risk to the minor’s life, severe physical harm, or substantial pain and discomfort if treatment is delayed.I grant permission for the attending physician to administer any medical or minor surgical treatment, x-ray examinations, and immunizations needed by the named child. Should a serious illness arise, major surgery be necessary, or a significant accidental injury occur, I understand that the physician will make every effort to contact me quickly. This authorization is given only after reasonable attempts have been made to reach me.I also grant permission to the staff and its affiliates, to provide necessary emergency treatment before the child is admitted to a medical facility.This release is valid for the duration of the camp session. I execute this release voluntarily, with the intention of enabling prompt medical care in emergency situations to protect the life and well-being of the minor child while I am not present.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE
Signature Field *

Clear
Date *
Registration and Tuition Costs
The cost associated with participation in the summer camp.
Registration Fee *
Price: $40.00
Tuition *
June 17-20 - $300.00
Total
$ 0

Participant

Medical Information

Parent / Legal Guardian Contact Information

Emergency Contact Information

Informed Consent and Acknowledgment

Medical Release and Authorization

Confirmation

Registration and Tuition Costs