Heart Camp Application

Child's First name

Child's Last name

Date of Birth

Gender

Male

Female

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Camper T-shirt size (please indicate youth or adult)

Parent or Guardian 1

Parent or Guardian 1 Phone Number

Parent or Guardian 1 Mobile Number (If different than home)

Parent or Guardian 1 Email

Email address to use for all information sharing prior to and after camp:

Parent or Guardian 1 has a different address than the child.

Parent or Guardian 1 Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Add another Parent or Guardian

Parent or Guardian 2

Parent or Guardian 2 Phone Home Number

Parent or Guardian 2 Mobile Number (If different than home)

Parent or Guardian 2 has a different address than the child.

Parent or Guardian 2 Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Emergency Contact

Someone other than parents, this section MUST be filled out):

Emergency Contact Name

Relationship

Emergency Contact Home Phone

Emergency Contact Mobile Phone (If Different than Home)

Emergency Contact Email

Emergency Contact Address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Authorized Adults

Please provide the name of adults authorized to take child from camp in your absence: (You must provide at least one name).

Authorized Adult 1 Name

Authorized Adult 1 Relationship

Authorized Adult 1 Phone

Authorized Adult 2 Name

Authorized Adult 2 Relationship

Authorized Adult 2 Phone

Unathorized Adults

Adults NOT authorized to take child to and from events (if applicable):

Unauthorized Adult 1 Name

Unauthorized Adult 1 Relationship

Unauthorized Adult 2 Name

Unauthorized Adult 2 Relationship

Signature

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I understand that, if any information I/we have provided (in any of the application forms) is found to be inaccurate, it may eliminate the opportunity for participation in camp.

I give permission to CTHeart Camp staff to discuss pertinent health information provided on any of the application forms (including medical forms) with any of my child's doctors, health care providers, school staff, camp staff, or other parties that is necessary to define my child's readiness for, and success at camp. Thi

Company name

Date

Heart Camp Application

Emergency Contact

Authorized Adults

Unathorized Adults

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