Child Registration

Registration Informational Form

Last Name

First Name

Select an Address

Phone

Contact Me By?

Phone

Child Last Name

Child First Name

Select an Address

Birthday

Please List All Allergies

Any child with vomiting, diarrhea or an auxiliary fever of 100 degrees either alone or in combination with other symptoms including sore throat, a rash in a contactable area or oozing and redness in the eye CAN NOT be cared for at Youth Empowerment Zone Summer Camp. If your child develops any of these symptoms while at the center, you will be contacted and advised. A sick child my not return to the center until 24 hours after the signs or symptoms have subsided, the fever is gone and treatment has begun. If a child shows symptoms of a suspicious rash, sores, purulent eye discharge, a physician must verify the diagnosis and begin appropriate treatment. Written documentation must be provided from the pediatrician concerning the condition of the child prior to returning.

Field trips will be planned as part of Youth Empowerment Zone Summer Camp. This will include walking to nearby areas as well as outdoor activates involving bus/or van transportation. Every possible precaution will be exercised to assure the safety and welfare of your child. However, all authorized agents shall not be responsible, financially or otherwise, should any accidents occur. This checked box gives Kid Power Summer Camp staff permission to take your child on any field trips and participate in any special presentations (example: Puppet shows, storytellers, etc.). IF ANY SPECIAL CIRCUMSTANCES, REGARDING FIELD TRIPS OR PRESENTATIONS, APPLY TO YOUR CHILD PLEASE NOTIFY YOUR DIRECTOR IN WRITING IMMEDIATELY.

Yes

Hospital/Emergency Permission: I authorize Youth Empowerment Zone Summer Camp to act as the agent of the parents in any emergency situation for the health and welfare of my child. I am responsible for the expenses involved if the service of a physician or hospital is required.

Yes

Photograph And Video Permission: I GIVE the Youth Empowerment Zone Summer Camp permission to take photographs/videos of my child for public relations and/ or marketing purposes. Photos will remain archived at Kid Power Institute home office and can be used for promotional purposes without notification.

Yes

Parent Signature

Thank You For Registering Your Child. Our Team Will Be Back With You Within 24-48 Hours.

YOUTH EMPOWERMENT ZONE

Registration Informational Form