Summer Camp Camper Information Form Camper Information*This form is to be completed after registering for camp and payment has been put through. Please submit only one form per camper.Child's First Name* Child's Last Name* Child Birth Date* MM slash DD slash YYYY Grade Entering in Fall 2024*Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeT-Shirt Size*Youth XSYouth SYouth MYouth LAdult SAdult MAdult LAdult XLParent/Guardian #1 Name*This person will be the primary person contacted while the camper attends camp. First Last Parent/Guardian #1 Phone Number*Parent/Guardian #1 Email* Parent/Guardian #2 Name First Last Parent/Guardian #2 Phone NumberParent/Guardian #2 Email Other than Parent(s)/Guardian(s), please list who you are authorizing to pick up your child (Full Name, Relationship, Phone Number)Emergency Contact Name* First Last *If neither parent, emergency contact, nor physician is available in case of emergency, Cheekwood will exercise judgement regarding medical treatmentEmergency Contact Phone Number*Emergency Contact Email* Physician Name* First Last Physician Phone Number*Allergy or Medical Concerns?* Yes No What is the Allergy or Medical Concern?* Will you be leaving medication with your child?* Yes No *Guardians leaving any medication with their child must complete a Medical Release Form.Medical Release FormConsent* In the event of the medical emergency listed above, I hereby grant full permission for a Cheekwood employee to administer the treatment outlined below. I will hold harmless Cheekwood and its employees from legal responsibility for any outcome of the administration of medication.Please list the medical emergency, the medication you are leaving with your camper & treatment plan*Is there anything we should know about your camper to help them have the best experience possible at camp? If your camper needs any special attention, considerations, or if there are things we should keep in mind about your camper, please briefly describe how we can best accommodate them. Please include any tips and tricks you use at home or at school during the year. Please note that we are not a special needs camp and there may be some needs we are unable to meet. If you’d like to talk to Cheekwood Staff about accommodations, please email [email protected] to set up a time to talk.Talent ReleaseBy checking this box, I grant permission without restriction, to Cheekwood Botanical Garden & Museum of Art to record my child's voice, image, and likeness for use in Cheekwood Botanical Garden & Museum of Art's advertising, programming, promotional material, or for whatever purpose they may deem appropriate. I release Cheekwood Botanical Garden & Museum of Art from any liability for any such violation of any private personal or property rights which I might have in connection with such materials.Do you grant permission?* Permission Granted Permission Not Granted