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Summer Day Camp Registration Form

***Registration for 2019 Summer Day Camp is now closed***

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1. Child's Information
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First Name
Last Name
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(mm/dd/yyyy)
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2. Child's Information

First Name
Last Name

(mm/dd/yyyy)

3. Child's Information

First Name
Last Name

(mm/dd/yyyy)

Primary Parent/Guardian's Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Secondary Parent/Guardian's Contact Information

First Name
Last Name



Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code


Parent's Authorization
In the event that my child needs immediate medical attention for injuries received while participating in a program at the Dana Adobe Cultural Center, I give my permission for the DANA staff members to administer necessary medical treatment. DANA staff may also admit my child to a hospital emergency room for emergency medical treatment without my consent if I cannot be reached to give permission.
Medical and Liability Release
The undersigned agrees to hold the Dana Adobe Nipomo Amigos and any other officer or employee thereof harmless from any claim for injury or accident to the above-named child/children arising out of or in any way connected with the named activity. I recognize that this program may have some inherent risks and I accept the responsibility to identify those risks and accept them. In case of an accident arising out of an activity, medical assistance may be administered to the person named herein. This registration form will act as a medical release. If the participant is under 18, a parent or guardian must sign a release.
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Official Nondiscrimination Statement
(USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, or political beliefs. Persons with disabilities who require alternative means of communication of program information (Braille, large print, audiotape, etc.) should contact SDA's TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.