Camp


To insure that we will have this required information on each student, this form
must be completed for each student prior to selecting classes.

Once this form is completed you will be re-directed to the class selection page.

For the safety and security of all students most of the information on this form is Required.

Student Information
  
   Student First Name

 (Required)

Student Last Name

 (Required)
     Birthdate
 (Required) Age:
   Grade

(Required)
Parent Information
  
    Parent/Guardian Name

 (Required)
   Address

 (Required)
  City

 (Required)
    State

 (Required)
    Zip

 (Required)
     Home Phone
(xxx-xxx-xxxx)
(Required)
    Cell Phone or Additional Phone Number
(xxx)xxx-xxxx
(Required)
     Parent or Guardian Email

 (Required)
   Business Name
 Business Address
    Business Phone Number
    Emergency Contact Name

 (Required)
     Emergency Contact Phone Number

 (Required)
    Emergency Contact Cell

 (Required)
Pick-Up and Drop-Off
  
  Pick up Person

(Required)
  Pick up Person Relationship

 (Required)
Pick up Person Phone
Additional Information
  Special Needs/Allergies
Please list any information concerning the child’s growth and development, any special needs and/or allergies including sunscreen and antibiotic ointments.
    Is your child on any medication?

(Required)
  If so, what?
   * The Lynn Meadows Discovery Center has my permission to obtain emergency medical treatment for my child.

 (Required)
  If no, please list instructions
   Child’s Doctor/Clinic

 (Required)
    Dr/Clinic Phone

 (Required)

Photo Release

I do hereby give The Lynn Meadows Discovery Center, his/her assigns, licensees, and legal representatives the irrevocable right to use my child’s name, picture, portrait or photograph in all forms and media (electronic and print) for advertising, trade, or any other lawful purpose. I waive any right to inspect or approve the finished product, including written copy that may be created in connection therewith. I have read this release and am fully familiar with its content.
  
(Required)