ADEC Summer Camp Registration

ADEC SUMMER CAMP June 11- August 4, 2012

Ages 5-15 Monday through Friday 9:00A.M. to 3:00 P.M.

Child's Identification

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone *

Cell Phone *

Emergency Phone *

Date of Birth *

Month

Day

Year

Gender *

If child does not go by his/her first name, what does he/she prefer to be called?

Parent/Guardian Identification

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Relationship to Child *

Emergency Person #1

This person should be a local person who may be notified in case of emergency or illness when the parents are not available

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Relationship to Child *

Emergency Person #2

This person should be a local person who may be notified in case of emergency or illness when the parents are not available

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Relationship to Child *

Emergency Person #3

This person should be a local person who may be notified in case of emergency or illness when the parents are not available

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Home Phone *

Work Phone *

Relationship to Child *

Medical Information

Diagnosis *

Allergies (food, medication, bees, sun) *

Does Your child take medication *

If yes, please state name, dosage, and the reason

Will the medication need to be given during camp hours? If yes, when?

Physical Needs Information

Please describe your child's mobility *

Please describe your child's hearing *

Please describe your child's vision *

Please describe your child's toileting *

Any restrictions and/or limitations? *

If yes, please list

Child's Information

How does your child get along with other children? *

What works best when disciplining your child? *

Please give any further information, which you believe, will be helpful to staff in understanding and caring for your child *

Tee Shirt size *

Camp Information

Camp will run from 9:00 A.M. to 3:00 P.M. Please Areive at those times to allow staff time for preperation. Fee for camp is $50.00 a week. The camp is located on the second floor of the YMCA building at 200 E. Jackson St. Elkhart IN

Emergency Medical Treatment

Give ADEC staff permission to transport my child to the closest hospital for treatment in case of accidents. *

Yes

Travel Authorization

Give permission for my child to leave for trips in a car, van or on public transportation for field trips. *

Yes

Picture Release

Give permission to have my child appear in any media coverage approved by the ADEC Summer Camp program. *

Yes

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ADEC Summer Camp Registration

ADEC SUMMER CAMP June 11- August 4, 2012

Ages 5-15 Monday through Friday 9:00A.M. to 3:00 P.M.

Our Services

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MENU

ADEC Summer Camp Registration

ADEC SUMMER CAMP June 11- August 4, 2012

Ages 5-15 Monday through Friday 9:00A.M. to 3:00 P.M.

Our Services