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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
NAME___________________________________________Date____________________
Last First Middle
ADDRESS________________________________________________________________
No. & Street City Zip
HOME TELEPHONE NUMBER (_____) ____________‐___________________________
PARENT’S CELL PHONE# (_____) ____________‐___________________________
STUDENT’S CELL PHONE# (_____) ____________‐___________________________
PARENT’S E‐MAIL ADDRESS ______________________________________________
STUDENT’S E‐MAIL ADDRESS ______________________________________________
YOUTH T‐SHIRT SIZE: XS____ S_____ M_____ L____ XL
ADULT T‐SHIRT SIZE: S____ M_____ L_____ XL____ 2XL____ 3XL ____ 4XL ____ 5XL
A $35.00 registration fee plus $50.00 payment for the first week of camp must be
paid to secure your campers spot. Submission of application DOES NOT Secure
your camper a spot without payment. EACH WEEK MUST BE PAID IN ADVANCE
OF YOUR CHILD ATTENDING. Drop in service is $12.00 a day.
NO REFUND POLICY:
DUE TO LIMTED BUDGET THERE WILL BE NO REFUND FOR ANY REASON ONCE PAYMENTS
ARE REMITTED.
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
PARENT PROFILE SHEET
CAMPER’S NAME: ________________________ AGE: _____ SCHOOL: ______
PARENT INFORMATION
Mother/ Stepmother/Guardian’s Name _______________________________________________
Name________________________________________________Date____________________
Last First Middle
Address_______________________________________________________________________
No. & Street City Zip
Home Phone (_____) ________‐____________ Home Phone (_____) ________‐____________
Cell Phone (_____) ________‐____________ E‐Mail: _________________________________
Father/ Stepfather/Guardian’s Name _______________________________________________
Name________________________________________________Date____________________
Last First Middle
Address_______________________________________________________________________
No. & Street City Zip
Home Phone (_____) ________‐____________ Home Phone (_____) ________‐____________
Cell Phone (_____) ________‐____________ E‐Mail: _________________________________
I/We would like to participate in Youth Nation Inc. Parental Activities ___
Best day and time for contact: ____ Morning ____Afternoon ____Evening
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
FIELD TRIP PERMISSION FORM
Child’s Name____________________________________________Date_____________
Last First Middle
Address_________________________________________________________________
No. & Street City Zip
Emergency Phone Number(s) NAME: ______________ # (_____) ________‐_________
NAME: ______________ # (_____) ________‐_________
NAME: ______________ # (_____) ________‐_________
I give my son/daughter permission to participate in off‐site field trips offered by Youth Nation
Inc. during the 2018 summer program. I release Youth Nation Inc. and its affiliates from
responsibility in case of any accident/injuries that may occur during these trips.
________________________________________ _________________________
Parent(s) or Guardian(s) Signature Date
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
CODE OF BEHAVIOR
In order to promote harmony in any closely knit family, guidelines are necessary to protect the rights, reinforce
the responsibilities and ensure the health and safety of each camp member. We would like to build a fine
tradition of working together effectively so that each camper can reach a level of personal fulfillment, by using
to the greatest extent, the opportunities that are offered.
We seek your commitment and cooperation in maintaining these essential rules and objectives during your
summer here at Youth Nation Inc.
CAMPERS RESPONSIBILITIES
1. PARTICIPATION: Campers have the responsibility of participating fully in the camp. Campers must
assemble in designated area and remain until next event or activity. Camper must pay attention to
instructions given and follow accordingly.
2. BEHAVIOR: Campers have the responsibility of avoiding any behavior that is detrimental to the
achievement of their own or other goals. Camper must cooperate in maintaining order at the camp, and
must encourage an atmosphere where everyone is respected including other campers. Most particularly,
students must refrain from engaging in conduct that violates the provisions of the Code of Behavior.
3. REPECT FOR STAFF: Campers have the responsibility of showing respect for the authority of the
camp staff. Students must obey directions, use only acceptable and courteous language, and avoid
actions that show contempt. Campers are encouraged to appeal authoritative decisions only through
appropriate channels.
4. REPECT FOR OTHER CAMPERS: Campers have the responsibility of showing respect for the
rights and human dignity of fellow campers. For example, campers must refrain from bullying, name-
calling, fighting, harassing, belittling, or engaging in deliberate attempts to embarrass or harm another
camper.
Campers and parents must understand that violation of the guidelines mentioned above will result in
disciplinary action and could lead to dismissal from the YOUTH NATION INC. Summer Camp with NO
REFUNDS OF LOST DAYS.
___________________________________ __________________________________
Parent(s)/Guardian(s) Signature Date CAMPER Signature Date
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
MEDICAL AUTHORIZATION & HEALTH HISTORY
NOTE: For the safety of your students, our policy is that no one will be allowed to participate in the YOUTH
NATION INC. Program until this form is completed and returned to us.
I, the parent or legal guardian of ________________________, a camper in the YOUTH NATION INC. Camp,
hereby delegates to the program the authority and consent to any and all medical, surgical, dental or hospital
care or treatment while he/she is a camper in the program. Such treatment is to be rendered by, or under
the jurisdiction of, a duly licensed physician or dentist. You are fully authorized to act in accordance with your
judgment in any such emergency and are absolved from any liability or financial responsibility in connection
therewith.
Child’s Name______________________________ Sex_________ Date of Birth _________ Today’s Date_______
Last First Middle
Parent/Guardian’s Name ____________________________________________ Phone (____) ______‐_____
Last First Middle Cell (____) ______‐_____
Address______________________________________________________Work (____) ______‐_____
No. & Street City Zip
***IMPORTANT*** PLEASE CHECK ONE Do you have health insurance? YES _____NO _____
If you checked YES above, you must complete all sections below. Do not leave any items blank. Write N/A if
not applicable.
Health Insurance Company ____________________________________________________________
Policy Holder or Employer _____________________________________________________________
Group of Policy Number ________________________ Effective Date of Coverage ____________
Additional Numbers: _________________________________________________________________
Dental Insurance Company ___________________________________________________________
Group Number ___________________________________ Effective Date of Coverage ___________
Doctor __________________________________________ Phone Number (____) _____‐_________
Dentist _____________________________________________ Phone Number (____) ______‐________
Additional Person to call in case of emergency:
Name: ______________________ Relationship _______________ Phone Number_____________
List all medicines – prescription/over‐the‐counter‐(reason for medicines) for student:
__________________________________________________________________________________________
______________________________________________________________________________
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
MEDICAL AUTHORIZATION & HEALTH HISTORY (CON’T)
Please explain any problem areas identified above: _________________________________________
___________________________________________________________________________________
Parent/Guardian Signature ______________________ Date _______________________
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
AUTHORIZATION TO ADMINISTER MEDICATION
Permission Form for Prescribed Medication.
This Authorization is Valid for the Current Youth Nation Inc. Summer Camp
TO BE COMPLETED BY THE PARENT/GUARDIAN
Student: ____________________ Date of Birth: ______________ Grade: ______
School: _____________________ Graduation Date: _______________________
I have read the policy and regulations pertaining to administration of medication. I request that (name of
student) ________________________________ receive the medication specified below at the Youth Nation
Inc. summer camp according to standard of Youth Nation Inc. policy. I understand the parent is required to
deliver medication to the Youth Nation Inc. program.
Self‐Administration: Youth Nation Inc. may self‐administer medication according to Youth Nation Inc. program
policies/procedures.
________________ ________________________________
Date Parent/Guardian Signature
TO BE COMPLETED BY THE PHYSICIAN OR AUTHORIZED PRESCRIBER:
Name of Medication: ______________________________________________________
Reason for Medication (optional): ____________________________________________
Form of Medication/Treatment: __ Tablet/Capsule __ Liquid __ Inhaler __Injection __Nebulizer
__ Other ______________________________________________________
Instructions: (Times and dose to be given at Youth Nation Inc. Program): __________________________
Start: __ Date form received __ Other date: ___________________________________
Stop: __ End of Summer Program
Restrictions and/or adverse reactions:
__ None anticipated __ Yes Please describe: ________________________________________
___________________________________________________________
Special Storage requirements: __ None __ Refrigerate Other: _________________
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
AUTHORIZATION TO ADMINISTER MEDICATION (CON’T)
The camper is both capable and responsible for self‐administering this medication
__ NO __YES, Supervised __Yes, Unsupervised
This student may carry this medication: __ YES __NO
PLEASE PRINT:
Physician’s Name: __________________________________________ Date ___________________
Address __________________________________________________________________________
Phone Number: ______________________________ Physician Signature: _____________________
OFFICE USE ONLY:
Date received: ________________________ Received by: __________________________________
Administrative Approval:
MEDICAL INSURANCE DISCLAIMER
IMPORTANT!!!
Treatments for all medical conditions and illnesses must be paid by your insurance carrier whether due to injury or
illnesses.
If your child needs urgent medical treatment, we will contact you, but we will proceed to take the student to a health
facility determined by Youth Nation Inc. administrative staff (NO EXCEPTION). Again, if treatment is for an illness or an
injury, you are responsible for any medical costs.
This agreement must be signed by a parent/guardian before the child is admitted to the Youth Nation Inc. Summer
Program.
_____________________________________________ ____________________________
(Student’s Name – Please Print) (Date)
_____________________________________________ ____________________________
(Parent’s/Guardian’s Signature) (Date)
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
ALT EMERGENCY CONTACT
FILL IN THE NAME OF AN ADULT, OTHER THAN PARENT, WE MAY CONTACT IN CASE OF EMERGENCY
_____________________________ _______________________ _______________________
Name Home Number Cell Phone
STUDENT’S SIGNATURE:
____________________________________________________________
PARENT/GUARDIAN SIGNATURE:
_____________________________________________________________
LIST EVERYONE AUTHORIZED TO PICK UP YOUR CHILD
(IF THIS LIST CHANGE NOTIFY YOUTH NATION INC. STAFF IN WRITING AS SOON AS POSSIBLE)
E‐MAIL INFO@YOUTHNATIONINC.COM OR FAX (248)335‐6059
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
________________________________ _____________________ _____________________
NAME HOME PHONE CELL PHONE
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
WAIVER, RELEASE OF LIABLILITY FOR INFLATABLES
I understand that there are risks involved with my participation in a Bounce House or any inflatable
structure/activity where I will be on or around inflatable devices such as “Obstacle Course”, “Giant
Slide”, and “Bungee Run” or any other type of object meeting the same description as those listed herein.
Falling, slipping, suffering injuries from jerking motions in some activities, collision with other occupants
and/or the inflatable itself or other objects, nausea, headaches, broken bones, getting hit with objects
being thrown or other types of potentially hazardous events are possible during involvement in such
devices. This constitutes my understanding of that involvement in a potentially dangerous activity with
accompanying risks of personal injury or death and loss or damage to personal property, and I hereby
voluntarily assume those risks.
This instrument shall remain in full force and effect indefinitely and shall inure to the benefit of my family
members, heirs, agents, legal representatives, successors and/or assigns.
I have read and understand the foregoing provisions of this WAIVER, RELEASE AND COVENANT NOT
TO SUE and I have executed this instrument voluntarily on this date.
(FOR ANY INDIVIDUAL LESS THAN 18 YEARS OF AGE, A PARENT OR GUARDIAN MUST SIGN
ON YOUR BEHALF AS WELL).
___________________________ ____________________________
______________________
Participant’s Full Name Guardian’s Full Name
Date
(Please Print) (Please Print)
____________________________
______________________ Guardian’s Signature
Participant’s Signature
(If Participant is under 18)
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YOUTH NATION INC. Registration Form
2019 Summer Camp (Please Print Clearly)
NOTES OR SPECIAL INSTRUCTIONS
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