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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.

THE FOLLOWING ARE PROHIBITED:


1. Selling, distributing, using, possessing illegal drugs, substances, materials, or alcoholic beverages.
2. Stealing money or property of others.
3. Vandalism, arson, or malicious destruction of property.
4. Students being in unauthorized areas, such as young men in the women’s bathroom or vice versa.
5. Leaving Camp boundaries without administrative permission and supervision.
6. Other serious misconduct not listed above that disrupts or interferes with the Camp.

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) 
 

Health History                YES    NO 


1. Allergies or reactions: (For example food, medication, other) 
2. Hay fever, asthma, or wheezing 
3. Eczema or frequent skin rashes 
4. Convulsions/Seizures 
5. Heart trouble 
6. Diabetes 
7. Frequent colds, sore throats, earaches (4 or more per year) 
8. Trouble with passing urine or bowel movements 
9. Shortness of breath 
10. Speech problems 
11. Menstrual problems 
12. Dental problems 
13. Emotional/Psychological i.e. ADHD 
14. Autism, cognitive impaired, or special needs 
15. Others  

 
 

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, ____________________________________ (please print), in consideration of myself or my child being permitted to


participate in the activity below in any way, hereby for myself, my family members, heirs, and personal representatives,
successors or assigns, assume any and all risks which might be associated with this event. I further waive, release,
discharge and covenant not to sue the Youth Nation Inc., (“YNI”), its affiliates, directors, officers, members, sponsors,
organizers, employees, volunteers, legal representatives, agents, successors and/or assigns, for any and all claims, costs,
including attorney’s fees, demands, causes of action, suits, injuries, damages of any kind whatsoever, or death, sustained
by me, which arise out of my participation in this event. I also agree to the use of film, photo, audio or videotape of my
participation in this event for any reason.

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.

Activity: Inflatable Activities during the Youth Nation Summer Camp

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).

NO PERSON UNDER OR OVER THE WEIGHT AND/OR HEIGHT LIMITS SHALL BE


PERMITTED TO BE INVOLVED IN THIS ACTIVITY.

___________________________ ____________________________
______________________
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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