Youth Connection Summer Camp Registration Form (Printable)

To register your child: Complete the registration form, sign and deliver to
the Eatonville Community Center, 365 Center Street West, Eatonville
or mail to PO Box 1021 Eatonville, WA 98328 .

Name of Youth (Last name)______________________       First Name________________________

Birthday   ______________   Age   ________   Grade   __________

Mailing Address__________________ Physical Address________________________

City__________________State______Zip________Phone_______________________

School: Elementary _____ Middle_____ High_____ Home_____

Mother __________________Phone Home ____________Cell____________________

Father __________________Phone Home _____________Cell____________________

Guardian ________________Phone Home ____________Cell_____________________

My Child/Youth will be picked up by _______________ Walk Home_______________

Brothers and Sisters of Youth _______________________________________________

Persons to be called in case of emergency (if you are unable to be reached)

Name______________________________________ Phone_______________________

Name ______________________________________Phone_______________________

Youth’s Physician ____________________________Phone_______________________

List special heath problems (allergies etc.) or other important information
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

I waive all rights and release all claims that might be had against the Youth Connection (TYC) hired or contracted instructors, and their employees and agents. For any and all injuries or losses which may be suffered because of my participation or my youth’s participation in any and all activities.

I consent to my youth’s participation in (TYC) programs and authorize the organization and its employees or agents to provide emergency treatment for my youth on my behalf. To the best of my knowledge, my youth has no physical or other conditions, which would interfere with his/her participation.

I give my permission to have my photo or the photo of my youth taken during the TYC program, to be used for publicity purposes by The Youth Connection.

____________________has permission to attend summer camp, which includes overnight camping at Columbia Crest School and day trips to the parks in Eatonville.

signature ________________________________________________