Participant's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date of Birth

Email Address

Gender

Primary Contact Person (Parent/Guardian)

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relation to Child

Secondary Contact Person/Guardian

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relation to Child

PHYSICAL INFORMATION**

Height - Weight - Eye Color - Hair Color

Does your child have any physical disabilities?

If YES, please explain:

Additional Information*

Please describe your child's personality (eating habits. likes/dislikes, shyness, etc.)

RELEASE CONSENT***

A parent's/guardian's verbal authorization for pickup must be received before your child will be released to anyone other than parent/guardian. If not received, and we cannot contact you, the child will not be released.

Please list family member(s)/friend(s) authorized to pick your child up:

First Name

Last Name

Phone

(###)

###

####

Relation to Child

Name of second person:

First Name

Last Name

Phone

(###)

###

####

Relation to Child

I CONSENT TO INFORM COACH SEAN/COACH PAT WHEN ANYONE OTHER THAN IMMEDIATE PARENT/GUARDIAN IS TO PICK UP MY CHILD

Print Name of Primary Contact Person - Signature of Primary Contact Person

Today's Date

YYYY

*PLEASE FILL IN EVERY BOX WHETHER IT IS RELEVANT OR NOT AND PRINT A COPY TO BRING WITH YOUR CHILD BEFORE SUBMITTING THIS FORM.

**NOTE - A MEDICAL CONSENT FORM WILL BE PROVIDED ON THE FIRST DAY OF CAMP ENROLLMENT AND MUST BE FILLED OUT IN ORDER FOR YOUR CHILD TO PARTICIPATE IN ANY/ALL ACTIVITIES.