Student Information

First Name *

Last Name *

Gender

Birth Date +

Grade

What participating city are you in? *

I will be starting the week of: *

What location will your classes be held? *

Primary Contact Information

Relationship to Participant *

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone

Alternate Phone

Email Address *

Physical Record

Do you have any physical conditions which may require emergency assistance? Accommodations can be made for individuals with disabilities. *

Yes

No

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached. I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

Parent's/Guardian's Signature *

clear

I understand that the Boss Jr. Summer Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Parent's/Guardians Signature *

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Photo Release

I hereby give permission for my child to be photographed during the Boss Jr. Summer Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentation and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed. I do not expect compensation and that all photos are the property of Boss Jr. and its affiliates.

Parent's/Guardian's signature *

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Referral Agent:

Agent Name *

Agent Code *

If no agent type "Nurepublic"

Waiver:

Boss Jr. and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred. Children's' photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e EMT, First Responder, and/or Physician.)

Parent's/Guardian's Signature *

clear