Session Preference - Choose One*

July 11 - 15
July 18 - 22

Camper's Name*

First Last

Camper's Date of Birth*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

1st Parent/Guardian Name

First Last

1st Parent/Guardian Cell Phone Number

1st Parent/Guardian Email

2nd Parent/Guardian Name

First Last

2nd Parent/Guardian Cell Phone Number

2nd Parent/Guardian Email

Emergency Contact Name

First Last

Relationship to Camper

Emergency Contact Phone Number

Name(s) of Person(s) OTHER THAN PARENT who are authorized to pick up the camper:

Primary Care Physician's Name

Primary Care Physician's Phone Number

List any known Allergies

List any known Medical Conditions

List any Medications and Dosages

Medical Insurance Provider Name

Medical Insurance Number

Will the camper require medications be administered during the program?*

Yes
No

Medical Attention*

I Agree

In the event of serious illness or medical emergency which requires immediate attention, I hereby authorize any treatment as deemed necessary and appropriate by medical personnel

Photo Release*

I Agree

I consent to having my child photographed and/or videotaped and I also consent to the imaged and/or video being used by INSIGHT and the Sherlock Center for marketing and communications purposes.

Transportation Consent*

I Agree

I give permission for my child to participate in off-site travel with supervision by INSIGHT program staff.

Drop Off and Pick Up*

I Agree

Drop off will generally be between 8 AM - 8:30 AM each day. Pick up will be at 4 PM each day. It is possible that on one or two days that drop-off will be a bit earlier and/or pick-up a bit later. Due to scheduling and staffing issues, campers must be dropped off and picked up at the designated times each day. Families will be provided with a specific daily schedule at least two weeks before camp begins.

T-Shirt Size*

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