Spring Junior Youth Camp

Name of Participant *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Name of Parent/Guardian *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

End of day *

Parents/guardians are responsible for participants at the end of each day (3:00 PM). Please select if your child is allowed to walk home alone or if you will be picking them up.

Walk home at 3:00 PM

Picked up at 3:00 PM

Outing *

Certain activities will take place outdoors and in close proximity to the school under direct supervision.

I give permission for my child to participate in outdoor activities during the camp sessions

Image Release *

Do you permit the use of photos and videos taken of the group’s activities that include your son/daughter to be used in the program’s promotional materials (eg. brochures, Instagram)?

Yes

No

Waiver *

I hereby give permission for my son/daughter to attend this summer program. I understand that the Junior Youth Empowerment Program will endeavor to provide my son/daughter with a safe environment. In the case of personal injury, loss or damage I, or a third party, will not hold Junior Youth Empowerment Program, its agents or volunteers responsible.

Yes