Child's Name *

First Name

Last Name

Mother's Name *

First Name

Last Name

Father's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother's Cell Phone *

(###)

###

####

Father's Cell Phone *

(###)

###

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Date of Birth *

MM

DD

YYYY

Would you like to order more t-shirts at an additional charge of $5 each? *

You are provided with two t-shirts per camper

Yes

No

Name of first person to contact if parents are not available *

First Name

Last Name

Cell Phone Number *

(###)

###

####

Name of second person to contact if parents are not available *

First Name

Last Name

Cell Phone Number *

(###)

###

####

Family Doctor's Name *

First Name

Last Name

Office Phone Number *

(###)

###

####

Does your child have any unusual health conditions? *

Yes

No

Asthma *

Yes

No

Diabetes *

Yes

No

Deafness *

Yes

No

Bee Sting Allergy *

Yes

No

Convulsive Seizures *

Yes

No

Surgical *

Yes

No

Other Allergy *

Please elaborate in the comments section

Yes

No

Sight Impairment *

Yes

No

Fractures *

Yes

No

Kidney/Bladder *

Yes

No

Wears Glasses *

Yes

No

Heart *

Yes

No

Emergency Treatment *

If emergency treatment is required, and the parents or legal guardian cannot be reached immediately, your signature in the space provided below empowers the school authorities to exercise their own judgment in calling the physician indicated above, or if not available, to transport the child to a hospital emergency room. Likewise, your signature below is not sufficient for the release of confidential information protected by Federal Law.

I have read the above statement

Parent Digital Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Child's Name *

First Name

Last Name

Please select one *

I/We authorize The Suryoyo Camp Committee to obtain, store, and/or use any photographs, slides, and/or videotapes of my child for public relations, marketing/advertising, and/or internal training purposes.

I/We DO NOT grant permission.

Today's Date *

MM

DD

YYYY

Camper Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent(s) or Guardian(s): *

First Name

Last Name

I have read the above statement regarding Release of Liability, Transportation and First Aid & Emergency Medical Treatment. *

I have read and agree with the above statements

Parent’s Digital Signature *

First Name

Last Name

Cell Phone Number *

(###)

###

####