BASCC Holiday BASCC Holiday Camp Registration Form Children's InformationChild's Name* First Last Birth Date* Date Format: MM slash DD slash YYYY Home Address* Street Address Town Zip Main Contact #* Add another child Second Child's Name* First Last Second Child's Birth Date* Date Format: MM slash DD slash YYYY Parent 1First Parent's Name* First Last First Parent's Work PhoneFirst Parent's Cell Phone*Add another parent?*NoYesParent 2Second Parent's Name First Last Second Parent's Work PhoneSecond Parent's Cell PhoneAdditional ContactsAdditional Contact Names & Phone NumbersPerson(s) who may NEVER pick up my children (Legal Documents Required)Name First Last RelationshipName First Last RelationshipUpload supporting documentation Drop files here or Medical's InformationAllergies?*Any diagnosed allergies/health conditions we should be aware of? If yes, what are the symptoms? Yes No Allergic Reaction ProtocolWhat's your child allergic to and how should we proceed in the case of an allergic reaction?Hospital Preference*In case of emergency, please check off your hospital preferenceMorristownOverlookSt. BarnabasBASCC Holiday CampRegistration AmountFirst Child Camp Registration Days*Please select all applicable days. Monday Tuesday Wednesday Thrusday Friday Second Child Camp Registration DaysPlease select all applicable days. Monday Tuesday Wednesday Thrusday Friday Total $0.00 General Permissions*I give my child(ren) permission to participate in all activities during the time he/she is in BASCC Camp. I am aware that I need to bring a bag lunch with a beverage for my child. Morning & afternoon snacks are provided. I give permission for the BASCC Camp staff to treat my child in case of a medical emergency. I understand that if it is a serious condition, I will be contacted at the above number I have listed above as soon as possible. Also, I give my child permission to participate in walks & trips to local facilities & businesses. Every precaution will be taken while walking, as the BASCC Camp staff will supervise the children. The Thursday Morning Club / Madison Community House does not discriminate and prohibits discrimination, as required by state and/or federal law, in all programs and activities, including employment and access to programs. I agreeParent's Signature*Credit Card* American ExpressDiscoverMasterCardVisaJCBMaestro Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.