Camper's Name* First Last Camper's Date of Birth* Date Format: MM slash DD slash YYYY 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 Number1st Parent/Guardian Email 2nd Parent/Guardian Name First Last 2nd Parent/Guardian Cell Phone Number2nd Parent/Guardian Email T-Shirt SizeShoe SizeEmergency Contact Name First Last Rleationship to CamperEmergency Contact Phone NumberName(s) of Person(s) OTHER THAN PARENT who are authorized to pick up the camper:Primary Care Physician's NamePrimary Care Physician's Phone NumberList any known AllergiesList any known Medical ConditionsList any Medications and DosagesMedical Insurance Provider NameMedical Insurance NumberWill the camper required medications be administered during the program?*YesNoMedical Attention* I AgreeIn the event of serious illness or medical emergency which requires immediate attention, I hereby authorize any treatment as deemed necessary and appropriate by medical personnelPhoto Release* I AgreeI 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 AgreeI give permission for my child to participate in off-site travel with supervision by INSIGHT program staff.