Girls 3-Day Camp Registration Form

  • The BUS System Girls 3-Day Camp Registration Form

    This form is required for your child to attend camp.

  • Camper's Information

  • Parents' Information

    Parent/Guardian 1
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contacts/Authorized Pickup

    Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.

  • Emergency Information

    Emergency Contact #1
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Information cont'd

    Emergency Contact #2
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical / Health Information

  • Does your child have any food, medication or environmental allergies?*
  • Allergies? Check all that apply*
  • 0/150
  • Does your child’s allergy/allergies require child care staff to monitor child for symptoms, take action if a reaction occurs, or give emergency medication to your child?*
  • Does your child have a special health or medical condition?*
  • 0/150
  • Does the special health or medical condition require child care staff to perform a procedure, or perform child specific care such as: to monitor your child for symptoms or administer medication during child care hours?*
  • Is your child currently using any medication, food supplement or medical food (such as electrolyte solution)?*
  • 0/150
  • If yes, does this medication, food supplement, or medical food need to be administered at the day camp?*
  • Does your child have any dietary restrictions, including those for medical, religious or cultural reasons?*
  • 0/150
  • Does this dietary restriction require a modified diet that eliminates all types of fluid milk or an entire food group?*
  • 0/200

  • Payment and Statement of Understanding

  • INFORMED CONSENT & ACKNOWLEDGEMENT

    I hereby give my approval for my child’s participation in any and all activities prepared by The Bancroft Urban Survival System, LLC during the 3 day summer camp. In exchange for the acceptance of said child’s candidacy by The Bancroft Urban System, LLC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless The Bancroft Urban Survival System, LLC and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against The Bancroft Urban Survival System, LLC including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

     

    MEDICAL RELEASE AND AUTHORIZATION

    As Parent and/or Guardian, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the The Bancroft Urban Survival System, LLC and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered camp. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

     

    CONFIRMATION

    BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. By signing below, I comfirm that the information provided is accurate and I understand and agree to the terms of this registration.

     

     

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