Jolly Jamboree
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Child's Name (first and last) *
Current School Attending *
Grade (use 0 for Kindergarten)
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Parent's Name (first and last)
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Address
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Parent's Phone
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Parent's Email
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Emergency Contact #1 (name and phone number)
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Emergency Contact #2 (name and phone number)
Emergency Contact #3 (name and phone number)
People authorized to pick up my child (list all names)
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Medical Information
Are there any special accommodations needed due to allergies, medical or physical limitations, disability or dietary constraints or other restrictions?
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If yes to medical, please list
How did you hear about this program?
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Zip Code (This is used for grant purposes only)
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What is your ethnicity? (This is used for grant purposes only)
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What is your gender?  (This is used for grant purposes only)
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What is your military affiliation? (This is used for grant purposes only)
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Acknowledgement
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I, the undersigned attest that I am legally responsible to give permission to the student named above to participate in the activities of the programs for which they have applied. I give permission to Sturgeon City of Jacksonville, NC and its partners to release and allow photography and identification (including first name, age and school) of my minor child for publicity, news coverage, promotional presentations and web presentations of its programs as needed. I understand that those associated with the camp will not share the birth date or other personal information except to medical personnel or as required by law. I give permission to camp staff to take reasonable actions should my child be injured or need treatment while making efforts to contact me or the persons named above for further guidance. I accept the responsibility of retrieving my child at any hour and at any place if my child becomes a discipline problem or is disruptive to the program or other students.
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