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Summer Camp Application

Summer Camp

Thank you for registering your Student(s) for the Peachtree Academy Summer Camp

Please complete all of the information on this form. At the bottom of the form is a "Next" button. Clicking next will take you to the Payment Form where you will be able to enter the number of students you want to attend for each event and also allow you to pay with PayPal or a Credit Card.

Child's Information

First Name

Last Name

Birth Date

Grade in the Fall

Gender

Male

Female

Address

City

State/Province

Zip/Postal

Parent or Guardian Information.

First Name

Last Name

Home Number

Cell Number

Email Address

Emergency Contact Information

First Name

Last Name

Relationship Relationship

Phone Number

Alternate Phone Number

Does your student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Does your child perform on grade level, above grade level, or need academic reinforcement this summer?

How does your child perform academically?

Informed Consent and Acknowledgement.

I hereby give my approval for my child’s participation in any and all activities prepared by during the selected camp. In exchange for the acceptance of said child’s candidacy by ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

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Summer Camp Application