Your Name *

First Name

Last Name

Phone *

(###)

###

####

Camper 1 Name *

First Name

Last Name

Camper 2 Name

First Name

Last Name

Primary Contact *

First Name

Last Name

Primary Contact Phone *

(###)

###

####

Secondary Contact

First Name

Last Name

Secondary Contact Phone

(###)

###

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Family Doctor *

First Name

Last Name

Additional Pickup *

Will anyone other than the primary and secondary parent/guardians listed above be picking up your child(ren)?

Yes

No

Additional Name

Will anyone other than the primary and secondary parent/guardians listed above be picking up your child(ren)?

First Name

Last Name

Does your child have any medical or dietary restrictions?

Yes

No

Epi-pen required?

Yes

No

Media Consent *

I give permission for my child(ren) to be photographed or filmed for training or promotional purposes on occasion during the period they are enrolled in the program.

Field Trip Consent *

I give permission for my child(ren) to attend daily outings within the city limits as planned by the staff and substitute staff when needed.

Accident/Liability Waiver *

I give permission for my child(ren) to attend daily outings within the city limits as planned by the staff and substitute staff when needed.

Emergency Medical Treatment

I give permission for my child to receive emergency medical treatment due to sudden illness or accident, including anesthetics and medication by a private Physician or Hospital.

Agreed Accommodation *

We Play Summer Day Camp is a privately-run day camp. We will do our best to accommodate all children. However, we have limited resources for children with special needs.

I comply and understand that We Play Summer Day Camp Inc. is not responsible or liable for anything outside of what they can accommodate.

I understand that We Play Summer Day Camp has full responsibility and the right to deny my child of care due to violent behaviors that endanger other campers, staff or to themselves with no refund of camp fees.