
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_________________
Name____________________________________ Phone ________________________ Relationship_________________
CAMPER PICK-UP AUTHORIZATION
(Parents must list themselves in addition to any other authorized individuals)
Parent/Guardian Authorization Signature: _____________________________________________________________
______________________________________________________ Phone:________________________________
______________________________________________________ Phone:________________________________
______________________________________________________ Phone:________________________________
______________________________________________________ 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