Center for Child and Family Achievement in Partnerships with Princeton-Blairstown Center at Gregory Elementary School. Student Permission Slip-Up Form

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Date: August 1-5, 2022 *Students Currently in 4th or 5th Grade*
Time: 8:30-4:00 pm.
Location: Monday-Thursday: Princeton Country Club Picnic Area
Friday- Princeton-Blairstown Center Campus

Please Complete Form To Sign-Up Your Child For 1 Week of Summer Camp! Contact Ms. Planter, Gregory School Parent Liaison for more information at 609-233-5748.

Parent's First and Last Name(s) *

Student's First and Last Name(s) *

Gender *

Male

Female

Age *

Tee Shirt Size *

XXL

Does the participant have any food allergies or dietary restrictions that we should be aware of? If yes, please explain. *

Name of Health/Accident Insurance Carrier or Policy # (if applicable): *

Does the participant have Asthma? *

Yes

Inhaler Needed? If yes, please check

Does the participant have any limiting, temporary, or permanent injuries, illnesses, conditions, or disabilities that may interfere with his/her participation outdoors? *

Yes

I give permission for my child to receive emergency care in the event I can not be reached. This includes transportation related to the participant. *

Yes

I give permission for my child to be administered prescribed or over-the-counter medications. *

Yes

Photo Release: I give PBC and CCFA permission to use photographs, videos, and audio of me or my child during the program. *

Yes

Home Address *

Parent Contact Number *

Parent Email Address *

Name and Phone Number of Emergency Contact *

Please provide any additional comments, or concerns that we should be aware of related to your child: *

Submit

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