Summer Camp Registration

CAMPER INFORMATION:

First Name* required

Middle Initial

Last Name* required

Address* required

City* required

State* required

Zip/Postal Code* required

Gender

Date of Birth* required

T-Shirt Size (kids sizes)* required

Name of Current School* required

Attended JA BizTown with their school?

Name of School That Camper Attended JA BizTown With

Insurance Provider (If Insured)


PARENT/GUARDIAN INFORMATION:

First Name* required

Last Name* required

Relationship to Camper* required

Primary Email* required

Address (If Different than Camper's)

City

State

Zip/Postal Code

Home Phone

Employer (if employed)

Doctor's Name (Type N/A If No Insurance)* required

How Did You Hear About Our Camp?* required


EMERGENCY CONTACT INFORMATION:

Please give full names and fill in all lines. List two local people who are authorized to pick up your camper and can be contacted in times of emergencies. All persons listed must show ID each time when picking up camper. If family circumstances are such that there are individuals permitted to ever pick up your camper, please provide a list of of names and court documentation:

Person 1

First Name

Last Name* required

Relationship to Camper* required

Primay Email* required

Address (If Different than Camper's)* required

City* required

State* required

Zip/Postal Code

Best Number to Reach Them* required

Alternate Number* required


Person 2

First Name* required

Last Name* required

Address (If Different than Camper's)

City

State

Zip/Postal Code

Best Number to Reach Them* required

Alternate Number* required


MEDICAL HISTORY:

Does your camper now or at any time in the past:

Have a Medical or Limiting Condition?* required

Have a Special Health Requirement?* required

Have Any Other Physical Psychiatric or Behavioral Problems?* required

Does Your Camper Take Any Type of Medication?* required

Do Any of These Medications Require Administration?* required

If answered yes, complete this medication authorization form and provide medication on the first day of camp.

Does Your Camper Have Any Allergies?* required

Date* required

If Yes, List All Allergies (One per Line)


STANDARD RELEASES:

Authorization for Emergency Medical Treatment

The undersigned hereby authorizes officials of Junior Achievement of Central Maryland to contact directly the persons named on this form and authorizes the named physicians to render such treatment as may be deemed necessary in their judgement, for the health of the child named above. I hereby release and discharge Junior Achievement of Central Maryland from any and all financial responsibility for the medical care and/or transportation of such child to receive medical care. I agree to indemnify and hold harmless Junior Achievement of Central Maryland from any and all claims, damages, costs, attorney’s fee or damages of any kind arising from participation in JA BizTown Camp by the child named above. No exceptions to this policy will be granted.

Camp Code of Conduct

All camper and parents participating in Junior Achievement camps must agree to follow the conduct and discipline policy. Failure to do so could result in dismissal from the program without refund:

• Use appropriate language.
• Avoid physical contact with other campers.
• Be respectful of JA staff and other campers.
• Behave in a manner that in not verbally or physically threatening.
• Behave in a manner that does not endanger themselves or other camper’s safety and welfare.
• Be tolerant and accepting of others in terms of race, religion and gender.
• Agree to follow posted rules regarding behavior, not limited to the items listed above.

Camp Discipline Policy:

• JA staff will alert parent of the problem behavior.
• JA staff will document the issue on the camper’s file.
• Parent will be required to pick up camper immediately if problem behavior continues.
• JA Camp Director and Education VP will determine if camper is allowed to return to camp.

Photo Release

Junior Achievement of Central Maryland has permission to use photographs/videos/testimonials of my camper in JA Promotional Materials or other local media.

Camp Fee and Cancellation Information

Camp Fee: M-F 8:00am - 5:00pm $250
In the event that cancellation becomes necessary, a written letter of cancellation must be received in our office 30 days prior to the start of camp. Payments will be refunded in the full amount, less a $50 administrative fee. Cancellations received 29 days to 10 business days before the registered camp start date will be refunded 50% of the payment, less a $50 administrative fee. *No refunds will be issued for camp cancellations less than 9 business days before the camp begins.

I agree to the payment amount and agree to the cancellation policy. I have read, signed, and understood the information contained in each of the above releases.

Electronic Signature* required