BLAZER LEARNING CENTERCAMP REGISTRATION PAGE
A space in the camp will not be held unless all release forms and registration information is complete.
All incoming 6th graders are encouraged to attend Boot Camp.
Confirmation of Registration with detailed agenda and pickup information will be mailed to attendees
Check all that apply:
Camps are from 9 am-3 pm unless stated diffrent
Blazer Summer Camp:
__ The Americas June 3-6
__ Africa June 10–13
__ Europe June 17 -20
__ 6th Grade Boot Camp July 22-23
CAMPER’S NAME_____________________________________________________________________ DOB_________________
GRADE (2013-14 Year) ___________ AGE___________ SEX___________
CITY ________________________________________ ZIP____________ HOME PHONE#_____________________
MOTHER’S NAME___________________________________ MOTHER’S CELL # ___________________
MOTHER’S EMPLOYMENT __________________________ MOTHER’S WORK #____________ EXT______
FATHER’S NAME____________________________________ FATHER’S CELL #_____________________
FATHER’S EMPLOYMENT __________________________ FATHER’S WORK #____________ EXT______
PERSON’S PERMITTED TO REMOVE CHILD* MOTHER YES___ NO___ FATHER YES___ NO___ *If answered to either is no, legal documents must be presented at time of registration
PERSON TO BE CONTACTED IN CASE OF ILLNESS, ACCIDENT OR EMERGENCY AND AUTHORIZED TO REMOVE THE CHILD FROM THE FACILITY IN ABSENCE OF PARENT. IF NONE, INDICATE “NONE’.
PHYSICIAN’S NAME______________________CITY________________ PHONE NUMBER______________
SPECIAL MEDICAL, ALLERGIES OR OTHER NEEDS _____________________________________________ ___________________________________________________________________________________
TRANSPORTATION will be provided to and from the day camp if the student lives within BMS district. My Child Will Be:
______PICKED UP BY THE BUS ______CAR RIDER Address Child Should Be Picked Up/Returned: _______________________________________ ___________________________________________
Registration Forms should be returned to
Blazer Learning Center, 96 Arnold Lane, Bloomfield, KY 40008
Or Fax 502-349-7203
Or drop off at BMS when staff is present
PARENT RELEASE FORM
GENERAL RELEASE OF LIABILTY
The undersigned hereby releases and forever discharges Bloomfield Middle School, the Nelson County School Board, their officers, agents, servants and employees, from all claims and demands the undersigned now has or hereafter may have on account of or in any way arising from personal injuries known or unknown to the undersigned at the present time and property damages resulting or that results from any occurrence which may happen to _______________________________________________ while participating in activities sponsored by the Summer Camp Programs at Bloomfield Middle School.
Parent/Guardian Signature Date Witness Signature
AUTHORIZATION FOR EMERGENCY CARE In case of an accident or serious illness, and the school is unable to reach me, I hereby authorize the school to contact the physician indicated on the application and to follow his instructions. If it is impossible to contact this physician, the school may make whatever arrangements necessary to provide care and treatment for my child. In case of accident or illness where immediate treatment of my child is not necessary but he/she is unable to remain at school, the school will contact me to arrange transportation for my child. If the school is unable to reach me, I authorize the school to contact one of the persons indicated on the Summer Camp Registration Form and request them to come to the school and transport my child home.
____________________________ _______________________________________ ____________
NAME OF CHILD PARENT OR GUARDIAN SIGNATURE DATE
PHYSICIANS NAME ADDRESS PHONE NUMBER
In order for our children to stay outside for an extended period of time, we recommend students have sunscreen applied. However, there are some students that are allergic to the ingredients in sunscreen or require specific brands. The school board policy does not allow teachers to give medications or apply medications without a doctor or parent’s consent and sunscreens are considered a topical medication. Please help us to keep your child safe by circling one of the options below for your child and signing your name.
Ø I have provided my child with sunscreen, want him/her to be allowed to apply sunscreen as needed and give him/her permission to participate in “Blazer Summer Camp”.
Ø My child is allergic to sunscreen and I wish for him/her to remain in a shaded area or the gym and I give permission for him/her to participate in fun activities provided in this area.
Student Name __________________________ Parent Signature _________________________________