Shark Wake Park 561
Camp Registration Form
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Email *
Childs First Name: *
Child's Last Name: *
Child DOB: *
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DD
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Does your child have any allergies? *
Child Allergies: *
Does your child take any medications? *
Child Medications: *
Street Address *
City *
Zip Code *
(Father/Guardian 1) First Name: *
(Father/Guardian 1) Last Name: *
(Father/Guardian 1) Phone Number: *
(Mother/Guardian 2) First Name: *
(Mother/Guardian 2) Last Name: *
(Mother/Guardian 2) Phone Number: *
Emergency Contact Name: (First & Last) *
Emergency Contact Phone: *
Authorized Sign Out/Pick Up List: *
Additional Children
Please complete additional children if applicable
Child #2: First Name
Child #2: Last Name
Child #2: DOB
MM
/
DD
/
YYYY
Child #2: Allergies & Medications
Child #3: First Name
Child #3: Last Name
Child #3: DOB
MM
/
DD
/
YYYY
Child #3: Alleriges & Medications
I hereby authorize Shark Wake Park to act for me according to their best judgment in any emergency requiring medical attention and hereby waive and release the camp staff and Shark Wake Park from any and all liability for any injuries or illness incurred while at camp. I understand that participation in various sports involves motion and as such carries with it the risk of injury. The camp is not responsible for personal items that are lost, stolen or damaged. All medical expenses incurred will be the responsibility of the camper’s family. In lieu of medical certificate signed by a medical doctor, I have no knowledge of any physical or mental impairment that would be affected by the named camper’s participation in the camp program. I also understand that the camp retains the right to use photographs, videotapes, motion picture recordings, or any other record of this event for publicity, advertising, or any legitimate purpose.
Type your full name below to accept these terms.
Signature: (First & Last Name) *
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