Clone of Summer Day Camp#1 July 6-10 2026

Student's Name

First NameLast Name

Grade

Age

Gender

Race/Ethnicity - This information is gathered for grant requirement and statistical purposes only and does not effect eligibility or camp access.

T-Shirt Size

Parent/Guardian Information

Name

First NameLast Name

Cell Number

Format: (000) 000-0000.

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Health Plan/Insurance

Physician's Name

Physician's Phone

Any Conditions that may affect student’s participation in activities

Please disclose any/all relevant medical conditions, allergies (including food allergies), cognitive challenges or other health or behavioral considerations to help us best support your child's experience throughout camp.

Informed Consent and Acknowledgment

I hereby grant permission for my child to participate in any and all activities organized and conducted by Back2Youth (B2Y) during the selected camp session.

In consideration of my child’s acceptance and participation, I acknowledge and assume all risks and hazards incidental to these activities, including those associated with transportation to and from camp, participation in activities, and any related events. I hereby release, waive, absolve, and hold harmless Back2Youth, its officers, directors, agents, employees, volunteers, and representatives from any and all claims, liabilities, damages, or causes of action arising out of or related to my child’s participation.

In the event of injury or illness, I further agree to waive any and all claims against Back2Youth, including its staff, counselors, affiliates, participants, sponsoring agencies, advertisers, and, where applicable, the owners or lessors of premises used for camp activities.

I understand and acknowledge that participation in outdoor and recreational activities involves inherent risks, which may include, but are not limited to, physical injury, fractures, paralysis, or, in rare cases, death.

By signing below, I confirm that I have read, understood, and voluntarily agree to the terms outlined in this Informed Consent and Acknowledgment.

Guardian Release

Behavior Policy Acknowledgement

Cell Phone Policy

Liability Release

Media Consent & Release

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.

Date

Signature

My Products

Camp Fee

$200.00 Quantity
Item subtotal:

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Total

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Back2Youth Summer Campout August 3–5, 2026

Student Information

My Products

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