Course Registration Form

Camper's Information

Camper's Name *

First Name Middle Name Last Name

Camper's Birth Date

Month Day Year

Camper's Gender

Camper's Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

School Name

Grade

Parent/Guardian Information

Parent/Guardian Name (#1) *

First Name Last Name

Parent/Guardian E-mail (#1)

Parent/Guardian Mobile Number (#1) *

Area Code Phone Number

Parent/Guardian Additional Phone Number (#1)

Area Code Phone Number

Parent/Guardian Occupation (#1)

Parent/Guardian Employer (#1)

Parent/Guardian Name (#2)

First Name Last Name

Parent/Guardian Email (#2)

example@example.com

Parent/Guardian Mobile Number (#2)

Area Code Phone Number

Parent/Guardian Additional Phone Number (#2)

Area Code Phone Number

Parent/Guardian Occupation (#2)

Parent/Guardian Employer (#2)

Person responsible for payment:

First Name Last Name

Does your child require a one-on-one aid? If so, there may be an additional cost.

Additional Info:

Any allergies we should be aware of?

Gluten Free Peanut Dairy Free Tree Nuts Soy Free

Below are select questions that will help our staff better understand your child and their needs. Please answer as honestly as possible.

Does your child have any specific diagnosis?

Yes No

If Yes, please list each diagnosis and when your child was diagnosed.

What are your child's main areas of interest and favorite activities?

What are your goals for your child while they are involved with our program?

Joins in play with others?

Responds to adult directions?

Appropriately shows affection to family members and friends?

Does not like to be touched, including affection?

Pushes, shoves, hits, bites, scratches or kicks friends in a group play situation?

Emergency Contact Information

Medical Emergency Contact #1 *

First Name Last Name

Medical Emergency Contact #1 Phone Number

Area Code Phone Number

Emergency Contact Relationship to Child

Medical Emergency Contact #2

First Name Last Name

Medical Emergency Contact #2 Phone Number

Area Code Phone Number

Emergency Contact Relationship to Child

Please list those people in addition to parents/guardians who are permitted to pick up your child:

Medical Release Information

Health Insurance Provider

Heath Insurance Policy Number

Primary Physician

Primary Physician Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Primary Physician Phone Number

Area Code Phone Number

Hospital Preference

Please list any medical problems, Required Treatment including any requiring maintenance medication (i.e. diabetic, Asthma, Seizures...etc) and Should Paramedic be called?

Is your child presently being treated for any injury or sickness, or taking any form of medication for any reason? If Yes, explain:

Is your child allergic to any type of food or medication? If Yes, explain:

Does your child require a special diet? If Yes, explain:

Has your child ever exhibited aggressiveness? If yes, are there any particular triggers?

Does your child experience "Melt Downs" that last longer than 30 minutes? If yes, pleas explain:

Have you ever been advised by a teacher, psychiatrist (including but not limited to the Help Group) that your camper requires one-on-one supervision for any reason at all? If yes, please explain why

*The purpose of the above listed information is to ensure that medical personnel have details of any problem, which may interfere with or alter treatment.

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

I understand that the Ed Asner Family Center or Camp Ed will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

In case of emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by a Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician.

I understand that I agree to allow my child to attend an end of the day processing group with a Licensed Marriage Family Therapist conducted by our Mental Health Director Chrisa Sadd, LMFT

I understand that I agree to be a part of a processing group with my peers. This group will be conducted by Navah Paskowitz-Asner as well as Chrisa Sadd, LMFT.

Companionship

While Camp Ed endeavors to provide ypour camper with companionship, comeraderie and funm we cannot be responsible for one-on-one care on a consistent basis. To the extent that your camper requires consistent one-on-one supervision, you are required to provide such.

Photo Release: I hereby give permission for my child to be photographed during Camp Ed, I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Camp Ed and The Ed Asner Family Center.

Transportation Release: I hereby give permission for the transportation of my child for official Camp Ed Activities by modes of transportation agreed to by the camp organizers.

The Ed Asner Family Center and Camp Ed are not responsible for lost or damaged personal property. All Scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's photos and quotes may be used for publicity purposes.

Once you click submit, The Ed Asner Family Center will reach out to you to make an appointment to discuss any extra support your child may require.

I Accept the above statement.

Select Day(s)

Monday January 6, 2019 Tuesday January 7, 2019 Wednesday January 8, 2019 Thursday January 9, 2019 Friday January 10, 2019

Camper Registration Form