Child Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent or Guardian *

Parent or Guardian

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

MM

DD

YYYY

Video/Photo Authorization *

I give permission for Rita’s Meals Made By Design Summer Camp to include my child in program photos and videos. I understand that these become the property of the said camps to be used for promotional purposes, and I authorize such use without compensation.

Yes

No

Authorized Pickup Designates *

First Name

Last Name

First Name

Last Name

First Name

Last Name

Behavior Discipline Policy *

Rita’s Meals Made By Design has the right to redirect & assert reasonable discipline as needed for behavior issues & reserves the right to revoke participation & membership to participants whose behavior impedes the learning or endangers other camp attendees. If for any reason membership is revoked payments will not be returned.

I have read the Behavior Discipline Policy

Release & Hold Harmless Statement *

I understand that despite safety precautions there is always a risk of accidental injury. I as the parent or guardian of the participant named herein, assume all risks and hazards incidental to any camp activities from responsibility and agree to indemnify and hold these businesses, camp counselors, directors, drivers, volunteers, and all employees harmless for any illness or injury to me, my child, or family members occurring during camp activities, field trips, or other recreational facilities. I have fully read the emergency authorization, medication policy, release & hold harmless statements, video/photo authorization, and behavior/discipline policy on this application. As a parent or legal guardian I hereby consent to having my child participate in the program & have gone over all needed information with my child.

I have read the Release & Hold Harmless Statement