LaunchTrack

Late Registration (After 5/24) - $235.00

First name:

Last name:

Address:

Address2:

City:

Province / State:

Postal / Zip Code:

Parent or Guardian Name:

Parent or Guardian Phone Number:

Email:

Grade Entering in Fall:

T-Shirt Size:

List high school or youth team (full name). If not on a team, list school:

Offensive Position:

Defensive Position:

Camper Height:

Camper Weight:

Camper Date of Birth:

Twitter Username:

Instagram Username:

Grade Point Average:

SAT (Math and Critical Reading):

ACT Composite:

Primary Guardian:

Parent information if not provided above (Name, Address, Phone Numbers):

Emergency Notification: You must specify a person to be notified if the above parents are unavailable (include phone number and relationship). We will attempt to contact parents first. This must be a person not listed above or residing at the same residence:

Health Care Provider Information (Name/ Phone Number):

Personal History:

If you checked off any of the personal history boxes please provide details:

Please list prescription and/ or non-prescription medications the camper takes at home (Diagnosis, Name of Medication, Route, Dosage, Frequency).:

Please list medication taken during camp hours including Rescue Inhaler and EPI PEN.:

This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed program activities, except as noted by me. We do herby waive, release, and forever discharge said organization, its staff, officers, agents, representatives, employees, and their successors and assign from any and all claims for damages occurring during the participant’s stay at camp, his/her participation in activities arising from traveling to or from camp, whether said accident, injury, or loss is due to negligence or not. I hereby give my permission for treatment of illness and injury at the Shore's Best Camp and for emergency medical treatment at the Hospital.:

Accept