2024 camp is full and registration is closed. Please check back next year for camp 2025!

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Child Information

Camper Name

First

Last

Date of Birth

Name of School

Grade

Known Allergies:

Parent/Guardian Information

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Name

First

Last

Phone

Relationship To Camper

Medical Concerns

Signature

Clear Signature

I give permission for J.Y.S.L.A to obtain emergency medical treatment, including emergency transportation for my child if I cannot be reached immediately. I aggree to be responsible for any emergancy medical expenses incurred. (If oarent/gaurdian/representative refues to sign, instructions must be attached stating what procedure the facility is to follow in an emergency.)

Printed Name of Above Signature

Authorized Alternate

Please designate an authorized alternate if you cannot pick up your child. DESIGNEE MUST BE AT LEAST 18 YEARS OR OLDER AND WILL BE REQUIRED TO PRESENT A VALID PICTURE ID.

Who Cannot Pick Up Child?

For the safety and security purposes of your child, is there anyone who DOES NOT have permission to pick up your child?

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