Healthy Living Camp - City of Alexandria Forms

HEALTHY LIVING

Plant, cook, eat and play! Kids will work up an appetite as they learn basic gardening, cooking, and healthy nutrition choices. Through fun and hands-on activities, kids will sow the seeds for healthy eating habits and active lifestyles.

Summer Day Camp Registration Form | Healthy Living

July 8 - 12 | 9AM - 12PM | Johnnie Varnado Business Center | Ages 8 - 18 |

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- Step 1 of 7

Section 1: Participant Information #1

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Gender *

Male
Female

Grade *

School *

Parish *

Participant Information #2

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Gender

Male
Female

Grade

School

Parish

Parent/Guardian Information

Name *

First

Last

Phone *

Email *

Place of Employment *

Work Phone *

Emergency Contact Person Name *

First

Last

Relationship *

Phone *

Medical Information

Please list current Health Problems/Allergies: *

Medications *

Preferred Hospital *

Doctor *

Phone *

Health History

Please attach additional pages if necessary, all information is kept confidential.

Child #1 Name *

First

Last

Child #1 has or is subject to: (select all that apply)

Asthma
Fainting Spells
Convulsions
Bloody Nose
Heart Trouble
Other

If other, please explain: *

Is your child(ren) diagnosed with a learning or physical disability, behavior disorder or is there any additional information concerning your child(ren) that we should be aware of? *

If yes, please explain:

Child #2 Name

First

Last

Child #2 has or is subject to: (select all that apply)

Asthma
Fainting Spells
Convulsions
Bloody Nose
Heart Trouble

If other, please explain:

Is your child(ren) diagnosed with a learning or physical disability, behavior disorder or is there any additional information concerning your child(ren) that we should be aware of?

If yes, please explain:

Parental/Guardian Consent

I, *

the parent/guardian of *

hereby give the permission necessary for my child(ren) to participate in the City of Alexandria summer day camp programs. I understand that my child(ren) will be involved in a wide variety of camp activities and I acknowledge that my child(ren) is capable of participating in these activities.

I agree, individually and on behalf of the minor child(ren), to assume all risks of participating in these programs and activities and do hereby release, hold harmless, and forever discharge the City of Alexandria, its employees, officials and volunteers from any and all causes of actions, claims, costs and demands that I may have individually or on behalf of the minor child(ren), by reason of any harm, accident, injury, or illness arising out of these summer camp activities.

I understand that if my child(ren) has a persistent pattern of negative behavior and interventions have not been successful, I may be asked to voluntarily remove my child(ren) from the program.

Should it be necessary for your child(ren) to have medical treatment while participating in these summer activities, and a parent/guardian cannot be reached, your signature below gives the City of Alexandria personnel permission to use judgment in obtaining medical treatment for your child(ren) and grants medical personnel consent to provide any medical treatment deemed necessary and appropriate. By signing below, you indicate your understanding that the City of Alexandria does not have insurance covering the cost of medical or hospital services for your child(ren) and that any such cost will be your sole responsibility. The City of Alexandria will not administer or supply any medication to your child(ren) at summer day camp.

Do you grant permission to City of Alexandria to take and use photographs and/or digital images of your child(ren) in printed materials, Facebook, email communications and the City of Alexandria website? *

I do
I do not

Payment Policy/Pick-Up

A payment of $25 per camp per child is due before each camp start date, upon approval of this application. ONLY CHECKS OR MONEY ORDERS WILL BE ACCEPTED. NO CASH, CREDIT/DEBIT CARDS ACCEPTED.

Children must be signed out each day from the camp program by a parent or guardian.

I agree to pay the designated fees in order for my child(ren) to attend summer day camp (including additional fees for late payment.) *

I agree
I do not agree

Release of Child

I hearby give my permission for my child(ren) to leave with the following persons:

Person 1

Please enter the individual's name and phone number.

Person 2

Please enter the individual's name and phone number.

Person 3

Please enter the individual's name and phone number.

Person 4

Please enter the individual's name and phone number.

By signing this form, you have verified that all information listed above is accurate to your knowledge and have read and understood all policies, waivers, and consents contained in this document.

I acknowledge that it is my responsibility to inform City of Alexandria summer day camp personnel if there is a separation, divorce, or other relationship issue that could impact my child(ren)’s safety. My child(ren) MAY NOT leave summer day camp with the following persons:

Person 1

Please enter the individual's name and relationship to the child.

Person 2

Please enter the individual's name and relationship to the child.

Person 3

Please enter the individual's name and relationship to the child.

Parent/Guardian Signature *

Date *

Note: All registrations and money can be mailed or dropped off at City Hall 915 3rd St. with ATTN: Community Services

Make money order or check payable to:

City of Alexandria

PO Box 71

Alexandria, LA 71309