GMG 2019 Summer Camp Consent & Release Form

This form give us important information such as allergies and whether or not the camp participant will need early drop off / after care /and lunch.

Please note we're unable to fulfill laptop loaner requests made after June 20.

Participant Information

Full Legal Name *

Camp Location *

Participant T-shirt Size

Size charts: Youth (S-XL) ; Adult (S-2XL)

*

Contact Information

Guardian Full Name *

Relationship to Camper *

Guardian Email Address *

Phone Number *

Secondary Contact Name *

Relationship to Camper *

Secondary Contact Email Address

Phone Number *

Summer Camp Services

Would you like us to provide lunch for the duration?

Participants have the option of bringing lunch from home, or having it catered for $10/day. Reduced cost of $5/day for students on financial aid. *

Do you to need to loan a laptop from GMG?

For participants without a computer, we’re happy to provide a loaner laptop at $5/day.
*

Do you need before care?

Early drop off 8:30-9:30am, $5/day. For participants on financial aid: $5/day, includes both before & aftercare
*

Do you need after care?

Late pick up 4:30-5:30pm, $5 per day. For participants on financial aid: $5/day, includes both before & aftercare
*

Is the participant attending on scholarship/financial aid?
This will impact your invoice for summer camp services
*

Yes, the student is on scholarship

No, the student is not on scholarship

Medical Information

Family Physician Name & Contact Information *

Participant’s Medical Insurance Provider *

Does the camper have any allergies? *

Yes

No

If yes, please explain

Medical conditions, previous injuries or special diet:

List of any medications and reasons for use:

End of Day Release Authorization

The following people are authorized to pick up my daughter.
(If same as Guardian and Secondary contacts, leave blank)

Photo & Video Release

Your child could be part of our promotional campaign or a press event!

Girls Make Games staff may take and use photos and or videos of participants for publicity purposes.

Photos and videos of our participants may be used on the Girls Make Games website, LearnDistrict website, Facebook, Twitter other media, e-newsletters and any other publications.

Consent *

I hereby grant LearnDistrict / Girls Make Games permission to use my, or my daughter's, likeness, name, voice and words in any broadcast, telecast or print media account of this event or activity.

I do not want my daughter photographed

Parent Permission and Signature

Consent *

I have carefully read, and fully understand the Girls Make Games Participant Agreement. I hereby give my permission for my daughter to participate in the program, and any and all of its activities, and agree to release, indemnify, and hold harmless LearnDistrict Inc. from and against any claim which I or my daughter or any other person may have for any losses, damages or injuries arising out of or in connection with my daughter's participation in the summer program.

Parent/Guardian Signature *

clear

Type Full Name *

Date Signed * +