C.A.P.S. Spring Break Camp Application 2025

STUDENT INFORMATION

Student First Name

Student Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone Number

Emergency Phone Number

Birthdate

Current Grade

Parent / Guardian Information

Parent First Name

Parent Last Name

Parent Home Number

Work/Emergency/Contact Phone

EMERGENCY CONTACT FORM

Parent / Guardian Place of Employment Address

Employment Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Work Phone Number

Family Doctor Name

Physician's Phone Number

Physician's Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital by car or ambulance for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, transport my child to

Transport Child

Check all that apply:

No medication of any type whether prescription or nonprescription may be administered to my child.

No medication of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.

I hereby grant permission for nonprescription medication to be given to my child if they become ill with symptoms such as headache, vomiting, sore throat, fever, diarrhea such as aspirin, throat lozenges, and cough syrup.

Allergies (Special Medical Information): Allergic reactions (medications, foods, plants, insects, etc.)

Vaccinations/Shots are up to date:

Yes

Most recent date of Tetanus Shot:

You should be aware of these known medical conditions of my child

Signature

Date of Signature

All information Must Be Current
You can also apply online.

Parent Email Address

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C.A.P.S. Spring Break Camp Application 2025

STUDENT INFORMATION

School Information

Parent / Guardian Information

EMERGENCY CONTACT FORM