Aquidneck Island Day Camp Registration Form

Camper Information

Date of Application +

Camper's Full Name

Date of Birth +

Age

Gender

Address

City

State

Zip

Phone

Email Address

Mother's Name

Cell Phone

Work Phone

Father's Name

Cell Phone

Work Phone

Other Legal Guardian

Cell Phone

Work Phone

List two other people (relatives, friends, neighbors) who could be called during camp hours in case of illness or emergency, if you cannot be reached. The individuals listed below are the only individuals authorized to pick up your child.

We will not release a child to anyone other than a parent/ guardian without written permission from that parent/guardian.

Guardian 1

Cell Phone

Work Phone

Address

City

State

Zip

Guardian 2

Cell Phone

Work Phone

Address

City

State

Zip

How did you hear about us?

Please check the dates you are registering for: (Please note there is no camp on July 4th)
Check the left-hand box for the full week or select individual days of that week

Full seven weeks (July 10th -August 25th)

Do you need after camp care from 4-5pm?

Yes

No

Please indicate if your child needs a car seat, has a special diet, or is prone to fatigue.

If there is any reason your child cannot participate in any of the offered activities in the weekly schedule please inform us.

Camper Medical History

Does your child have all his or her immunizations up to date?

Yes

No

Does your child have any allergies? (Such as to bees, dairy, peanuts, medications, etc.)

Yes

No

If yes, please list them:

Does your child require any special accommodations?

Yes

No

If yes, please explain:

Does your child display any behaviors that we should be aware of?

Yes

No

If yes, please explain:

Does your child have any health problems?

Yes

No

If yes, please explain:

Please explain any recent surgeries or medical procedures:

Will your child need to take any medication during camp hours?

Yes

No

If yes, please notify the Camp Coordinator at 864-3183 to make arrangements.

Parents Authorization:

This health history is correct to the best of my knowledge and my child has permission to engage in all planned activities, except as noted. In the event that I cannot be reached in an emergency, I hereby authorize Aquidneck Island Day Camp to secure proper medical treatment for my child named herein. I understand that proper medical treatment may include hospitalization, anesthesia or surgery in a critical situation.

Physician's Name

Physician Phone Number

Physician Address

City

State

Zip

Health Insurance Name

Policy #

Parent/Guardian's Signature *

Date * +

Waiver of Liability and Assumption of Risk

The purpose of this form is to make you aware of the specific risks associated with participation in the Aquidneck Island Day Camp. By signing this form, you are approving participation for your child in the camp from July 5th, 2022 - August 19th, 2022.

I have been informed and am fully aware of:

I understand that there are inherent risks associated with sports, swimming, sailing, horseback riding, music, art and other activities provided by the Aquidneck Island Day Camp. I agree to allow my child to participate in the activities offered at the camp unless otherwise noted in writing on the camp application.

I have been informed and am fully aware of the fact that Aquidneck Island Day Camp provides transportation to activities during the camp day. I understand that en route to or from, at, or in the vicinity of the program facilities, my child may be exposed to the risk of personal injury or suffer property damage or loss due to circumstances beyond the control of the program or its

I have been informed and am fully aware of the fact Aquidneck Island Day Camp makes every effort to ensure the safety of persons participating. I understand that despite this fact, my child may still be at risk of injury due to circumstances beyond the control of the program or its facilitators.

I hereby acknowledge that I have been provided with the opportunity to read this document that I am signing it of my own free will and for my benefit and that of my child in order for my child to gain permission to participate in the program.

Parent/Guardian Signature for Waiver of Liability *

Date * +

Name of Camper

Date of Birth +

Address

Telephone

City

State

Zip

Authorization for Publicity Related Release of Photo/Information

Name

Address

City

State

Zip

I,

authorize Aquidneck Island Day Camp, P.O. Box 4091 Middletown, RI 02842

To use my child’s first name and last initial only and photos for publicity purposes such as brochures, newsletter, flyers, videos, photomontages or press releases.

I understand that photographs may be used for publicity purposes such as thank you letters, brochures, facebook, newsletter, flyers, videos, or website for the Aquidneck Island Day Camp.

Please check one:

I request the option of reviewing any/ all photos of my child prior to agency’s use in printed format.

Please do not contact me again for authorization to use a specific photograph of my child prior to use in printed format.

I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.

NOTE: Further disclosure of any confidential information beyond that which is specified herein is prohibited without express written consent by the person authorizing this release.

I HEREWITH RELEASE AND HOLD HARMLESS AQUIDNECK ISLAND DAY CAMP AND ANY OF ITS AGENTS, EMPLOYEES, DIRECTORS, OR VOLUNTEERS FROM ANY LIABILITY FOR THE RELEASE OF ANY INFORMATION PROVIDED IN ACCORDANCE WITH THIS DIRECTIVE.

Signature of Parent/Guardian for Publicity Authorization *

Date * +

July 10th - 14th	Mon	Tue	Wed	Thu	Fri
July 17th - 21st	Mon	Tue	Wed	Thu	Fri
July 24th - 28th	Mon	Tue	Wed	Thu	Fri
July 31st - August 4th	Mon	Tue	Wed	Thu	Fri
August 7th - 11th	Mon	Tue	Wed	Thu	Fri
August 14th - 18th	Mon	Tues	Wed	Thur	Fri
August 21st - 25th	Mon	Tue	Wed	Thu	Fri