Confluence · Camp Confluence Spring Break 2024 Registration

Parent/Legal Guardian Name(s)

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First Name

Last Name

Email

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Verify Email

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Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Cell Phone

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Home Phone

Work Phone

Emergency Contact other than parent (Name and Number)

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Camper Name

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Camper's Age

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Camper's T-shirt size

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School attended by Camper

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People authorized to pick up my child (Name, Relationship, Phone)

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Child Check In and Out Procedures

When dropping off child/children for camp, parents/adults must escort them to the front desk in the lobby and initial the enrollment/sign in sheet. At the end of camp, parents/adults will need to check in again at the front desk to pick up children and initial the sign-out sheet. Please, try to be on time when dropping off and picking up children.

Dietary Restrictions

Food Will Be Provided. There will be a light breakfast, lunch and snacks daily for the kids. We will try to accommodate dietary restrictions to the best of our ability but cannot guarantee we will be able to meet them. You are always welcome to send your own food for your child.

Dietary Restrictions

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Medical or Other Special Needs

It is your responsibility to let Camp Counselors know of any medical or special needs that they should be aware of for your child’s safety.

Medications needed during the day (Can they self administer or do they need assistance?)

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Allergies

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Medical Release

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In case of emergency and I cannot be reached, I authorize Confluences staff to obtain whatever medical treatment they deem necessary for the welfare of my child. I hereby release, indemnify and hold harmless Confluences Directors and their staff from any and all claims arising out of injury to my child. I also agree to accept full financial responsibility for medical care provided to my child in case of an emergency.

Doctor’s Name and Number

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Preferred Hospital Name and Number

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Insurance Company and Policy Number

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Photo Release

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As part of this camp program, we will take photos and videos. These pictures, videos, and interviews may be shown during a school event or appear on the Confluence website. Please check ONE of three and read each option carefully.

I give my permission for my child to be photographed and videotaped with name published for all purposes, including Confluence’s website.

I give my permission for my child to be photographed or videotaped without any personal identifiers for all purposes, including Confluence’s website.

I do not give my permission for any photographs, videotapes, or interviews of my child to be published or used for any purpose.

Liability Release and Parental Consent Form

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In consideration of participation for this summer camp program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to my child as a result of their participation in said summer program. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks.

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