firebase

• Camper Information

• Camper Name
  First NameLast Name
• Age
• Date of Birth
  -Month -DayYear
• Gender
• Phone Number
  -Area CodePhone Number
• Email
  example@example.com
• Address
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
• School Name
• Grade/Level
• T-shirt size
  Extra SmallSmallMediumLargeExtra Large

• Medical Information

• Blood Type
  Please Select Type A Type B Type AB Type O
• Please let us know if you have any allergies, existing illnesses or any medical conditions.
• Are you currently taking any medication? If yes, please provide the generic name and its purpose?
  
  

• Parent/Guardian Details

• Parent/Guardian Name
  First NameLast Name
• Phone Number
  -Area CodePhone Number
• Email
  example@example.com
• Address
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code

• Emergency Contact Details

  If parent/guardian cannot be reached.
• Contact Name
  First NameLast Name
• Phone Number
  -Area CodePhone Number

• Payment Details

• Camp Fee: $49

• Payment Method
  CashCheckCredit Card

• Acknowledgment, Authorization, and Waiver

• This camper has my authorization to engage in the activities of the ABC Camp program.

  I allow taking photography of this camper that can be used for Camp ABC portfolio or advertising.

  I authorized ABC Camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if they are unable to contact the parent/guardian. I allow them to apply first aid, medical or surgical diagnosis and treatment as necessary.

  I allow ABC Camp to provide or administer the medication or supervise in self-administration.

  I release ABC Camp and any of its coaches, staff, and manager for any responsibility in case of accident, illness, or injury during this camper's enrollment.

• Date Signed
  -Month -DayYear

  Date
• Parent/Guardian Signature
  Powered by Jotform Sign Clear

• CAMP ABC
  1734 Whaley Lane, Menomonee Falls, WI, 53051
  262-532-4174 - info@campabc.com - www.campabc.com

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