2024 Village of Palm Springs Fall Camp Registration Form

User information

• First name
• Last name
• Email

Additional information

• Child's Last Name
• Child's First Name
• Child's Middle Name
• Street Address?
• City
• Zipcode
• Are you a resident of Palm Springs?
• E-mail Address
• Mother's Name
• Mother's Work Phone Number
• Mother's Cell Phone
• Father's Name
• Father's Work Phone
• Father's Cell Phone
• Legal Guardian's Name (If different from Mother/ Father)
• Legal Guardian's Phone Number
• Primary Parental Contact
• Primary Parental Contact Phone Number
• Child Date of Birth
• Child T-Shirt Size
• What school does the child attend?
• Password
• Emergency Contact #1- Name
• Emergency Contact #1- Relation
• Emergency Contact #1- Phone Number
• Emergency Contact #1- Address
• Emergency Contact #2- Name
• Emergency Contact #2- Relation
• Emergency Contact #2- Phone Number
• Emergency Contact #2- Address
• Family Doctor
• First Additional Person Authorized to pick up your child -Name
• First Additional Person Authorized to pick up your child -Relation
• First Additional Person Authorized to pick up your child -Phone
• Second Additional Person Authorized to pick up your child -Name
• Second Additional Person Authorized to pick up your child - Relation
• Second Additional Person Authorized to pick up your child -Phone
• Does your child have special needs
• If your child has special needs- please indicate
• Is your child toilet trained?
• List any special medical issues, allergies or medication instructions you feel we should be aware of:
• Does your child take any medication at home?
• If your child does take medication please list the name, dosage & frequency, time adminstered and possible side effects below
• Will your child be taking medicine during program hours
• If your child will need to take medication during program hours- please list the name, dosage & frequency, time adminstered and possible side effects below
• Does your child know how to swim
• How would you rate your child's swimming abilities?
• Language primarily spoken in home?
• What activities or skills are you or your child hoping to receive from this program?
• How did yor hear about our program
• PERMISSION TO PARTICIPATE IN FOOD RELATED ACTIVITIES
• My child HAS a food allergy or dietary restriction. He or she may participate in activities, but must not eat or handle the following items (please list below)
• AUTHORIZATION FOR EMERGENCY MEDICAL CARE in the event of a serious illness or accident and if parents cannot be reached. (signature)
• DROP OFF/ PICK UP PROCEDURES
• GENERAL PHOTOGRAPHY RELEASE
• COVENANT NOT TO SUE