BASCC Summer Camp BASCC Summer Camp 2021 - PDF Registration FormChild's InformationOne Registration Per ChildChild's Name* First Last Birth Date* MM slash DD slash YYYY Home PhoneHome Address* Street Address Town Zip Parent 1First Parent's Name First Last First Parent's Work PhoneFirst Parent's Cell PhoneEmail Add another parent?* No YesParent 2Second Parent's Name First Last Second Parent's Work PhoneSecond Parent's Cell PhoneEmail Additional ContactsAdditional Contact Names & Phone NumbersPerson(s) who may NEVER pick up my ChildLegal documents requiredPlease specify Name and RelationshipLegal Documents*Any legal documents that might help us enforce this rule. Drop files here or Select filesMax. file size: 64 MB. Medical InformationChild's HeightChild's WeightChild's Eye / Hair ColorChild's Doctor First Last Doctor's Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Health Insurance CarrierHealth Insurance Policy NumberDoes your child have any physical or health conditions we should be aware of?* Yes NoDescribe your child's physical or health conditionDoes your child have any diagnosed allergies – food, drug, insect, other?* Yes NoDescribe your child's allergies, symptoms & medications if applicableDoes your child take any medications on a regular basis?* Yes NoState your child's medication & conditionIs your child in good health and able to participate in Madison BASCC activities?* Yes NoPlease indicate reasonMy child may participate in walks around Madison to local facilities and parks.* Yes NoPlease indicate reasonHospital Preference*In case of emergency, please check off your hospital preference Morristown Overlook St. BarnabasMedical Release Form*In the event that my child should have a sudden illness or accident at the Madison BASCC Program, I understand that the staff will attempt to reach me immediately. If I cannot be reached immediately and if the staff members in charge view the situation as critical, the Madison Rescue Squad will be called. I hereby give permission for my child to be transported by emergency vehicle to a nearby hospital emergency room and given whatever aid is necessary. It is also understood that I will be responsible for all costs involved in the treatment of this minor child. I agreeBASCC Photography ReleaseDuring the BASCC Summer Camp we take photos of the children participating in special events or camp activities.Photography Release* I GIVE the BASCC program permission to use my child’s photo for news articles, website or promotional displays. I DO NOT give the BASCC program permission to use my child’s photo for news articles, website or promotional displays.BASCC Summer CampPlease check off which week(s) your child(ren) will attend at $225.00 per week per child.Let's Get Moving*Date: June 21 - 25 Half Day: 9AM to 1PM Skip this Week RegisterLet's Get MovingBASCC Summer Camp Full Week - Half Day - $225.00Let's Get MovingCrafty Kids*Date: June 28 – July 2 Half Day: 9AM to 1PM Skip this Week RegisterCrafty KidsBASCC Summer Camp Full Week - Half Day - $225.00Craft Kids ProductSurf's Up*Date: July 7 – July 9 Half Day: 9AM to 1PM Skip this Week RegisterSurf's UpBASCC Summer Camp Full Week - Half Day - $225.00Surf's Up ProductFull Steam Ahead*Date: July 12 – July 16 Half Day: 9AM to 1PM Skip this Week RegisterFull Steam AheadBASCC Summer Camp Full Week - Half Day - $225.00Full Steam Ahead ProductNature Wonders*Date: July 19 – July 23 Half Day: 9AM to 1PM Skip this Week RegisterNature WondersBASCC Summer Camp Full Week - Half Day - $225.00Nature Wonders ProductUnder the Sea*Date: July 26 – July 30 Half Day: 9AM to 1PM Skip this Week RegisterUnder the SeaBASCC Summer Camp Full Week - Half Day - $225.00Under the Sea ProductAwesome Art*Date: Aug. 2 – Aug. 6 Half Day: 9AM to 1PM Skip this Week RegisterAwesome ArtBASCC Summer Camp Full Week - Half Day - $225.00Awesome Art ProductSimple Science*Date: Aug 9 – Aug 13 Half Day: 9AM to 1PM Skip this Week RegisterSimple ScienceBASCC Summer Camp Full Week - Half Day - $225.00Simple Science ProductTotal $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*Card Details Cardholder NameSection BreakPost Tags Separate tags with commasPost Tags Separate tags with commasPost Title CommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later Δ The BASCC Program has the right not to accept a child if you are past due on payments.