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Child Information

Camper Name
Date of Birth

Parent/Guardian Information


Emergency Contact

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.)
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.
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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