First Child's Name
*
First Name
Last Name
Birthday
*
MM
DD
YYYY
Pronouns
*
Second Child's Name
First Name
Last Name
Birthday
MM
DD
YYYY
Pronouns
Third child’s information:
(please include name, birthday, gender, & pronouns)
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Relationship to Child
*
Address (if different than child’s):
Parent/Guardian Name
First Name
Last Name
Phone
(###)
###
####
Email
Relationship to Child
Address (if different than child’s):
Child's Physician
*
First Name
Last Name
Physician Phone
*
(###)
###
####
Physician's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Name of Health Insurance
*
Policy #
*
Person carrying insurance
*
Relationship to participant
*
List all possible allergies (foods, drugs, insects, other)
*
List all possible reactions
List any health conditions and/or concerns (including if s/he sunburns and/or overheats easily)
*
Emergency Contact #1
*
Relationship to Child
*
Cell Phone
*
(###)
###
####
Home/Work Phone
(###)
###
####
Emergency Contact #2
*
Relationship to Child
*
Cell Phone
*
(###)
###
####
Home/Work Phone
(###)
###
####
Phone
(###)
###
####
Relationship to Child
Authorized Pick-Up Person #2
Phone
(###)
###
####
Relationship to Child
Authorized Pick-Up Person #3
Phone
(###)
###
####
Relationship to Child
What are your hopes and fears for your child in regards to this program?
*
Restrictions
*
Please describe restrictions or adaptations needed to ensure our program is accessible for your child
Are you comfortable with your child going barefoot in environments deemed “safe enough” by the Play Project staff? These environments may include grassy parks and some forest areas and may contain some hazards such as bees and unseen sharp objects. (Yes/No/or Explain):
*
To what extent is your child comfortable and confident around water?
*
Would you like your child to reapply sunscreen on days when we have prolonged sun exposure?
*
The Play Project may use images and sounds of participants and staff to share with enrolled families and/or to promote future programs of The Play Project. Please check the box that is most appropriate:
*
(Please note: The Play Project does not use social media and no images taken during summer camp programs will be posted on social media).
Is there anything else about your child that would be helpful for us to know?
Please select which session(s) you'd like to register your child for:
*
(select all that apply)
Would you like to register your child for the full session (both weeks) or for one week of the session ?
*
If one week only, please specify which week your prefer:
Additonal details you’d like to include about the sessions you are registering for?
(for ex: registering siblings for different sessions)
Would you like to sign up for early (9am) drop-off?
If yes, please list the weeks you would like early drop-off:
What is your preferred payment method for your remaining balance (after the $50/session/child deposit)?
*
I have read and agree to abide by The Play Project Policies:
*