Neoversity Midterm Camp
Registration Form
Camper's Information
Student
*
First Name
Last Name
Date of birth
*
-
02
-
09
2014
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Year/Grade
*
Select Grade
PK
KG
1
2
3
4
5
6
Camper's School
Please select camp
*
Neoversity Learning Center/ Al Furjan Pavilion
Arcadia School/ JVT
Please select Dates
*
February 14th - February 18th
Please provide any additional information that you think is important or may affect the camper's ability to fully participate in the camp program.
Parents' Information
Parent/Guardian
Parent/Guardian
*
First Name
Last Name
Phone number
*
E-mail
*
Relationship to Child
*
Parent/Guardian 2
Parent/Guardian 2
*
First Name
Last Name
Relationship to Child
*
Mobile Phone
*
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Emergency Contacts/Authorized Pickup
Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you.
Emergency Contact
Full Name
*
First Name
Last Name
Primary Phone Number
*
Relationship to Child
*
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Medical / Health Information
Is the Camp up-to-date on all immunizations?
*
Yes
No
Allergies? Check all that apply
Food
Medication
Environmental
Please list and explain any allergies
0/150
Does your child have a special health or medical condition?
*
Yes
No
Please explain
0/150
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Payment and Statement of Understanding
I give permission for all media, including photographs, film footage, or tape recordings, which may include my or my child's image or voice for purposes of art, advertising, education, or promotion, or for any other purpose consistent with the Mission, and release from any claim or liability to that use. I waive all rights to inspect it/or approve any text that may be used in conjunction with the media and the use to which it may be applied. Kindly type NO if you do not agree.
*
Type first and last name above to consent
Sign Document
*
Date Signed
*
-
Month
-
Day
Year
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