GATEWAY CITADEL - 2007 Basketball Camp Registration Form

2007 BASKETBALL CAMP REGISTRATION FORM

THE SALVATION ARMY GATEWAY CITADEL EMERGENCY & HEALTH INFORMATION FORM

Please fill out completely and return to: The Salvation Army Gateway Citadel Community Center 824 Union Rd., St. Louis, MO 63123 Phone: 314-631-0727 Fax: 314-631-3494

PLEASE USE ONE FORM PER CHILD AND PRINT NEATLY.

Child's first name __________________________ Middle initial_____ Last name_________________________________ Gender_____ Age_____ Birthdate__________ Preferred name___________________________________

Child resides with: Mother_____ Father_____ Both_____ Other_____

Mother/Guardian's first name___________________________ Last name_________________________________________ Address_____________________________________________________ City_________________________ State______ Zip_____________ Work phone________________ Home phone_________________ Cell/pager___________________

Father/Guardian's first name____________________________ Last name________________________________________ Address_____________________________________________________ City__________________________ State______ Zip_____________ Work phone________________ Home phone__________________ Cell/pager___________________

How did you hear about us? School_____ Word of mouth_____ Brochure_____ Other_____ Years at camp:_____

__________________________________________________________________________________________________________

EMERGENCY CONTACTS AND PICK-UP AUTHORIZATION

The following people should be contacted in case of emergency, only if parent or guardian cannot be reached.

1. Name____________________________________ Relationship to child________________________ Phone: Day______________________ 2. Name___________________________________ Relationship to child________________________ Phone: Day______________________ 3. Name____________________________________ Relationship to child_______________________ Phone: Day______________________ 4. Name____________________________________ Relationship to child_______________________

Persons UNAUTHORIZED to pick up child from facility:

1. Name_____________________________ Relationship to child_______________________________

2. Name_____________________________ Relationship to child_______________________________

PLEASE COMMENT ON YOUR CHILD'S SWIMMING ABILITY: Non-swimmer___ Limited experience___ Swimmer___ Any restrictions on swimming/water activities?_______________________________________________________
___________________________________________________________________________________________

________________________________________________________________________________________________________

IS THIS CHILD TAKING ANY MEDICATIONS? Yes___ No___ If yes, what kind and why:________________________________________________________________________
____________________________________________________________________________________________

If medication needs to be administered during the program, a Medication Permission Form must be completed. Forms available at The Salvation Army.

DO ANY OF THE FOLLOWING APPLY TO YOUR CHILD, AND IF SO, PLEASE EXPLAIN: ___ Special needs___________________________________________ ___ Allergies or asthma_______________________________________ ___ Dietary restrictions________________________________________ ___ Chronic or recurring illnesses_______________________________ ___ Operations or serious injuries (include date/s)___________________ __________________________________________________________ __ Restrictions on physical activities_____________________________ Status of child's vision, hearing and speech___________________________________________ _____________________________________________________________________________

OTHER SIGNIFICANT INFORMATION ABOUT YOUR CHILD'S BEHAVIOR/NEEDS THAT WOULD BE HELPFUL TO KNOW: _________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Contact: - Search - Log On