BCYC Summer Registration
We are offering eight weeks of full day programs, Monday - Friday, 8am-4pm, $130 weekly
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Email *
Best form of contact *
Week Registering *
Required
Participant Name *
Participant Date of Birth *
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Parent/Guardian Name *
Parent/Guardian Occupation *
Phone *
Address *
Photo Release:  I understand that photographs of participants are taken during BCYC activities. Images including my child/the participant may be published by the Bandon Community Youth Center on Facebook, Website or printed materials. *
Required
Emergency Contact  (Name, Relationship to Participant, Contact Number)                                                   *
Emergency Contact  (Name, Relationship to Participant, Contact Number)                                                   *
Emergency Contact  (Name, Relationship to Participant, Contact Number)                                                   *
Please use this space to inform us of any information we should know about the participant.
Please list any medications (over the counter or prescibed) include medication (name, dosage) when taken (specific times, purpose.
Physicians name and contact information *
Dentist name and contact information *
Name of insurance and policy number *
Participant is allowed to receive
Please list all known allergies including food, drug, latex, and insect stings:
Authorization for Consent to Medical Treatment     Any individual under the age of 18 years without a completed Consent to Medical Treatment form on file prior to the start of camp will not be able to participate in any camp activity. The directors and staff are not responsible for any medical, dental or other expenses resulting from accidents.I hereby authorize the Bandon Community Youth Center Summer Camp staff to consent to any diagnostic procedure (including x‐rays), to the administration of any medical or surgical treatment, or to any hospital care when any, or all are rendered under the general supervision of any physician and/or surgeon licensed under the provisions of Oregon Revised Statute 677, the Medical Practice Act.  My child/the participant is in good health and I know of no medical reason why he/she cannot participate in any camp activities.  This authorization is given in advance of any specific diagnosis, treatment or medical care being required. By typing your name you are agreeing to the above.
I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing Bandon Community Youth Center from all liability on my and the Participant’s behalf, (b) promising not to sue on my and the Participant’s behalf, (c) and assuming all risks of the Participant’s participation in this Activity, including travel to, from and during the Activity.  Please type your name below to agree. *
I allow Participant, to participate in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death.  I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document.  I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made by me. Please type your name to agree. *
I the parent or guardian of the participant understand that additional signed forms are required as well as payment to complete registration. Please type your name to agree.
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