Charlotte Youth Broadcasting Camp

Charlotte Youth Broadcasting™ Camp

Registration Form
For ages 9-12 and 13-17

Cost Per Week (day camp): $375.00 1st child, $325.00 2nd child, $275.00 3rd or more

Cost for Overnight: $1,150.00 (mandatory $250 deposit)

Lunch Included or [Opt Out] If opt-out, Parent/Guardian will provide child(ren) lunch (no price adjustment).**Any food allergies are an automatic opt-out lunch. Parent MUST provide lunch according to your child(ren) needs**

A $60.00 deposit (non-refundable) per camper, per week, is required to hold your camper(s) space. Remaining balance must be paid 7 days prior to first day of each camp week.
How many campers are you registering today? (Maximum campers per registration form is 3) *
Type Number of Campers Here
How did you hear about CYBC? *

Facebook Google Search Magazine Ad Yard Sign Word of Mouth

Parent/Guardian Information
Parent Full Name *

First Name Last Name
Relationship *
Email Address *

Confirmation Email
Address *

Street Address

Street Address Line 2

City State

Zip Code
Mobile Number *

Area Code Phone Number
Work Number

Area Code Phone Number

Policy Agreement
The Charlotte Youth Broadcasting Camp considers all registrations without regard to race, color, religion, sex, national origin, or the presence of medical condition or handicap. However, the Charlotte Youth Broadcasting Camp does reserve the right to refuse admission to any child who may require a level of attention beyond that which the Charlotte Youth Broadcasting Camp are designed to accommodate or who may require specialized training that may prevent the Charlotte Youth Broadcasting Camp staff from adequately meeting the needs of the child(ren). All campers are to follow all rules of the Charlotte Youth Broadcasting Camp. Campers are expected to be respectful of Instructor(s) and other campers, participate in activities, follow instructions, no foul language, dress appropriately, weapons are prohibited, and Zero Tolerance for bullying and violence. Furthermore, you give permission for your Child(ren) to be transported to and from the main camp site for off-site field trips in the vehicle(s) manner of which Charlotte Youth Broadcasting Camp deems necessary [not limited to hired shuttles, personal vehicles, and or chaperone’s vehicles]. I have read, understand, and agree that my child (ren) will comply with all policies and procedures of Charlotte Youth Broadcasting Camp, failure to do so shall result in removal from camp without a refund of any payment(s). It is understood that the camper(s) is enrolled for the entire weekly session; no deductions or refunds will be made for cancelling, absences or withdrawal, voluntary or involuntary. I agree as a parent or guardian to indemnify and hold harmless Charlotte Youth Broadcasting Camp, its owner, and staff in the event of any incident or accident that may occur with traveling of the camp.
Initials *

Media Release
I give my permission for photographs, video footage, audio recordings and on-camera interviews to be conducted with my and by my child(ren) for CYBC and any other third parties that CYBC allows. I give permission for my child(ren) during camp hours to create a social media profile (not limited to a website, Blog, articles, and or, DVD). My child (ren) image and or likeness may be exclusively used for an indefinite time for promotional purposes on television, newspapers, magazines or any other digital/print media deemed necessary by Charlotte Youth Broadcasting Camp. It is fully understood, there are no royalties or compensation in any amount owed to me nor my child(ren).
Initials *

Medical Release
Has your child(ren) or an immediate family member of your child(ren) been diagnosed with COVID-19 (CoronaVirus) or been directly exposed to COVID-19 (CoronaVirus) within the last 30 days? *
Please type your name *

First Name Last Name
If you have answered no to the above question please sign the below box to verify that your response is truthful and based on the best of your knowledge. *

Clear
We would like to thank you for your interest in Charlotte Youth Broadcasting Camp. In order to proceed with your child(ren) application, we asked that you provide medical documentation releasing your child to attend this summer's camp. All documentation can be emailed to charlotteybc@gmail.com, please title the subject line with the following: Your Child(ren) First and Last Name, CYBC Medical Release. The medical release must include the date of exposure to COVID-19, the primary doctor's note must state that he/she is Corona Virus /COVID-19 free.

We thank you for your understanding and we look forward to your camper attending this summer's camp.
Does your Child have a medical condition(s)/ diagnosis to where they need care beyond normal measure? *
If you have answered yes to the above question, please provide a detailed description in the space below. *
I am aware that my child(ren) will be participating in broadcasting activities that will require physical involvement and the use of electronic devices, which is associated with broadcasting. All physical activities can carry with them the risk of physical injury. On behalf of my child(ren) and myself, we assume all risk and agree that Charlotte Youth Broadcasting Camp and its owner(s), director(s) faculty, chaperone(s), staff and agent(s) shall not be liable, I shall "hold harmless" (known as "indemnify") CYBC in any way for any injuries sustained or loss of property during attendance at the Charlotte Youth Broadcasting Camp, nor shall CYBC be liable during any activity or any of its related functions. I agree to extend and uphold the hold harmless in the event my child(ren) contract(s) any symptom(s) or diagnosis of Covid-19 or Corona while in attendance at CYBC.
Initials *
This registration form is correct to the best of my knowledge and the child(ren) herein described has permission to engage in all activities, except noted by me. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injection of surgery for my child.
Medical Insurance Policy # *
Family Physician Name *
Family Physician Number *

Area Code Phone Number
Please list ALL current/past medical conditions and ALL allergies (incl food allergies). The Parent / Guardian is solely responsible for providng any medication (and the instructions) that must be administered to their child(ren) while at camp. *
**Any food allergies are an automatic opt-out lunch. Parent MUST provide lunch according to your child(ren) needs**

Food Allergies Opt-In Waiver
I acknowledge that my child(ren) has a food allergy and or food allergies, and I fully understand that by choosing to Opt-In for the camp meals, that I shall hold harmless and covenant not to sue Charlotte Youth Broadcasting™ Camp in the event of any type of reaction/consequences as a result of my child(ren) drinking, digesting, and or eating any food or beverage provided by Charlotte Youth Broadcasting™ Camp. Furthermore, by signing this meal waiver form, I fully understand the risk that I am taking by not providing my child(ren) food according to their dietary needs.
Initial *

Emergency Contact Information
LIST 2 NAMES AND PHONE NUMBERS OF PERSONS TO CONTACT IN CASE OF EMERGENCY IF YOU’RE NOT AVAILABLE. THESE INDIVIDUALS SHOULD BE AUTHORIZED TO PICK UP YOUR CHILD AND MAKE MEDICAL DECISONS.
Contact #1 *

First Name Last Name
Relationship *
Same address as Parent/Guardian
Address *

Street Address

Street Address Line 2

City State

Zip Code
Mobile Number *

Area Code Phone Number
Home Number

Area Code Phone Number
Contact #2 *

First Name Last Name
Relationship *
Same address as Parent/Guardian
Address *

Street Address

Street Address Line 2

City State

Zip Code
Mobile Number *

Area Code Phone Number
Home Number

Area Code Phone Number
LIST ANYONE NOT AUTHORIZED TO PICK UP YOUR CHILD
Full Name (Not Authorized)

First Name Last Name
Please explain
(If the person is a legal parent/guardian you must have legal documents from the court stating this person is not allowed to pick up your child.)
*

I acknowledge that I have read, fully understand, and agree to comply with all above releases and the policies and procedures of the Charlotte Youth Broadcasting Camp.The Undersigned, on his or her behalf and on the behalf of his or her child(ren), hereby releases, waives, discharges and covenants me not to sue.
Parent/Guardian Printed Name *
Parent/Guardian eSignature *

Clear
Date Signed

Month Day Year
Date
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