BASCC Summer 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 Home PhoneParent 1First Parent's Name First Last First Parent's Work PhoneFirst Parent's Cell PhoneAdd 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 ChildPlease specify Name and RelationshipLegal Documents*Any legal documents that might help us enforce this rule. Drop files here or 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?*YesNoDescribe your child's physical or health conditionDoes your child have any diagnosed allergies – food, drug, insect, other?*YesNoDescribe your child's allergies, symptoms & medications if applicableDoes your child take any medications on a regular basis?*YesNoState your child's medication & conditionIs your child in good health and able to participate in Madison BASCC activities?*YesNoPlease indicate reasonMy child may participate in walks around Madison to local facilities and parks.*YesNoPlease indicate reasonHospital Preference*In case of emergency, please check off your hospital preferenceMorristownOverlookSt. 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.Your child’s swimming abilitySwimming AbilityBeginnmerIntermediateAdvancedMy child has earned a Deep Water Badge from the Madison Community PoolYesNoBASCC Summer CampPlease check off which weeks and/or days your child will attend. If your child attends FULL DAYS for 8 WEEKS you'll get a $200.00 DISCOUNT if paid in full in one lump sum.Full or Half Days*Full DaysHalf DaysSummer Camp Week/DaysSports & Games*Skip this weekFull WeekSome daysSports & Games - Half Days*Skip this weekFull WeekSports & Games - Day Campers Monday Tuesday Wednesday Thursday Friday Venture in to Nature*Skip this weekFull WeekSome daysVenture in to Nature - Half Days*Skip this weekFull WeekVenture in to Nature - Day Campers Monday Tuesday Wednesday Thursday Friday Now You’re Cooking*Skip this weekFull WeekSome daysNow You’re Cooking - Half Days*Skip this weekFull WeekNow You’re Cooking - Day Campers Monday Tuesday Wednesday Thursday Friday Stem*Skip this weekFull WeekSome daysStem - Half Days*Skip this weekFull WeekStem - Day Campers Monday Tuesday Wednesday Thursday Friday Kids in the Kitchen*Skip this weekFull WeekSome daysKids in the Kitchen - Half Days*Skip this weekFull WeekKids in the Kitchen - Day Campers Monday Tuesday Wednesday Thursday 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 EmailThis 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. The BASCC Program has the right not to accept a child if you are past due on payments.