Camp Kay Registration

Parent or Legal Guardian Name (1)*

First Last

Relationship to Child*

Parent or Legal Guardian Mobile Number (1)*

Parent or Legal Guardian Work Number (1)

Parent or Legal Guardian Email (1)*

Is the parent or legal guardian's address the same as child's above?*

Parent or Legal Guardian (1) Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent or Legal Guardian Name (2)

First Last

Relationship to Child

Parent or Legal Guardian Mobile Number (2)

Parent or Legal Guardian Work Number (2)

Parent or Legal Guardian Email (2)

Parent or Legal Guardian Address (2)

Please fill out if different than child's home address and/or parent or legal guardian (1).

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Marital Status*

Single
Married
Divorced
Widowed

If divorced, who (full name) has legal custody?

Emergency Information

Food allergies?*

Yes
No

If Yes, please list food allergies and action to take in case of emergency.

Medication allergies?*

Yes
No

If Yes, please list medication allergies and action to take in case of emergency.

Chronic physical problems?*

Yes
No

If Yes, please list chronic physical problems and accommodations Kay School should make.

Pertinent developmental information?*

Yes
No

If Yes, please list pertinent developmental information.

Special accommodations needed?*

Yes
No

If Yes, please list special accommodations needed.

Child's physician*

Physician's phone*

Child's Health Insurance

Policy/ Group Number

HMO Number

Emergency Contacts: Names and addresses of two people to contact if parents cannot be reached (other than parent/ guardian)

Contact #1 Name*

First Last

Relationship to Child

Contact #1 Telephone Number*

Contact #1 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact #2 Name*

First Last

Relationship to Child

Contact #2 Telephone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Other persons authorized to pick-up child (other than parent/ guardian)

Other Authorized Pick-Up Contact #1

If you intend for someone other than a parent/ legal guardian to pick-up your child at Kay School, we need their information and a notification from you prior to the arrangement. Please have the person picking up bring their ID. We check all identification for new adults picking up at Kay School.

First Last

Relationship to Child

Telephone Number

Other Authorized Pick-Up Contact #2

First Last

Relationship to Child

Telephone Number

Person(s) NOT authorized to pick up child.

If a parent is not allowed to pick up child, appropriate paperwork such as the divorce/ custody decree must be brought in to Kay School and given to Director.

Name

First Last

Relationship to Child

Name

First Last

Relationship to Child

Kay School

Camp Kay Registration

Camp Kay Summer Registration 2018

Step 1 of 3

Emergency Information

Emergency Contacts: Names and addresses of two people to contact if parents cannot be reached (other than parent/ guardian)

Other persons authorized to pick-up child (other than parent/ guardian)

Person(s) NOT authorized to pick up child.

Agreements and Waivers