BASECAMP

Please ensure you read and complete all portions of this registration form.

Please contact us if you need any assistance or if you have any questions. Thank you.

2820 McFarlane Rd , Coconut Grove, Fl 33133 (786)-290-5150 www .basecampmiami.org

Name of Camper: ______________________________________________________ Grade ______

Address ____________________________________________________ City , State, Zip Code_________________________________

Phone Number ________________________________Male/Female _________ Age _____ Birth Date ________________

Name of School ___________________________________________________T-Shirt size _____ S ____M ____L ____XL ____XXL

FAMILY INFORMATION:

Parent/Guardian (First/Last/MI) ____________________________________________________ Home Phone ________________________

Address__________________________________________________ Employer ________________________________________________

Work Phone ________________________ Work Address___________________________________________________________________

Cell Phone _________________________ Alternate Phone #________________________________________

Parent/Guardian (First/Last/MI) ____________________________________________________ Home Phone _________________________

Address__________________________________________________ Employer _________________________________________________

Work Phone ________________________Work Address_____________________________________________________________________

Cell Phone _________________________ Alternate Phone #________________________________________

EMERGENCY CONTACT

In case of emergency if we can not reach a parent/legal guardian please list two emenrgency contacts.

Name____________________________________ Phone ________________________ Relationship_________________

CAMPER PICK-UP AUTHORIZATION

(Parents must list themselves in addition to any other authorized individuals)

Parent/Guardian Authorization Signature: _____________________________________________________________

• ______________________________________________________ Phone:________________________________

Week 1 6/14 to 6/18___ Week 2 6/21 to 6/25 ___ Week 3 6/28 to 7/2___ Week 4 7/5 to 7/09____ Week 5 7/12 to 7/16____ Week 6 7/19 to 7/23___ Week 7 7/26 to 7/30 ___ Week 8 8/2 to 8/6___ Week 9 8/9 to 8/13___

SUMMER CAMP 2010

CAMPER EMERGENCY INFORMATION &

EMERGENCY TREATMENT CONSENT FORM

Camper Information

Camper Name (First/Last/MI) ____________________________________Grade (Fall '10) ____________

Date of Birth:_________________________ Age:____________

Camper's Address ______________________________________________________________________

City________________________________ State______________ Zip Code___________________

Phone___________________________________ Cell Phone: ________________________________

Health Information

Child's Physician____________________________________ Phone_____________________________

Address ______________________________________________________________________________

Insurance Co. ______________________________ Policy Holder Name_________________________

Employer Group #_____________________________________ Member #________________________

Please advise us of any learning disabilities, emotional or physical conditions to assist us in providing the best camp experience for your child.

____________________________________________________________________________________________________________________________________________________________________________

List any or all medications which your child will bring with him/her to camp:

Medication Medical Condition To be Given When/How

_________________________ __________________________________ _____________________

Allergies: List all known allergies

Allergies Describe reaction and management of reaction

______________________________________ ___________________________________________

Important Please Read and Sign Below

In the case of an emergency and if I cannot be reached, I authorize the staff of Base Camp Miami to obtain whatever medical treatment he/she deems necessary for the welfare of my child. I further

understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment regardless of whether or not my medical insurance would cover such charges and fees. I am the parent or legal guardian of the minor____________________________________, and I am signing on behalf of said minor.

__________________________________ ___________________________________

Print Name of Parent/Guardian Signature of Parent/Guardian

2010 Summer Camp Consent Form

Name of Child____________________________________________________________

Address_________________________________________________________________

Birth Date___________________________________________ Age________________

School Attended__________________________________ Grade (Fall '07) _______

Parent/Legal Guardian_____________________________________________________

Phone: Home_________________ Work_________________ Emergency___________

I, __________________________, hereby authorize my child,____________________ to participate in any and all programs sponsored by the Basecamp Miami, and hereby waive, release, absolve, indemnify and agree to hold harmless Basecamp Miami, and its employees there of; participants, persons transporting the participants to and from activities, and any other individual, group, organization or corporation under contract with Basecamp Miami, for any claim arising out of an injury to the participant. I understand that Basecamp Miami is not responsible for any personal items, ect, lost during this program and I will discourage my child from bringing such items.

______________________________________________ ____________

Parent/Legal Guardian Date

My child has parental consent to attend all field trips and activities sponsored by Basecamp Miami, unless I provide the camp with a written letter stating otherwise.

______________________________________________ ____________

Parent/Legal Guardian Date

I grant the right for my child's _________________________________ image or likeness to be used for marketing or printing purposes associated with the promotion and marketing and news story coverage of parks and recreation related activities. I give my permission to Basecamp Miami for any photos or video footage of my child

_________________________________ taken during the course of this summer camp program to be used for educational, promotional, or any other purpose by Basecamp Miami.

______________________________________________ ____________

Parent/Legal Guardian Date