Youth STEAM Camp

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Youth S.T.E.A.M. Camp Application 2020 Page 1

* Indicates required field

Student's Name *

First

Last

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Student ID (for office use only)l *

Last four digits of student's social security number *

Grade Level *

Gender *

Date of Birth *

Race/Ethnicity *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Student Shirt Size *

Total Household Income *

Parent/Guardian/Foster Care Information:

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Home Phone Number *

Cell/Work Phone Number *

Family Arrangement *

Person(s) authorized to be contacted *

Mother Father Both Neither

person authorized to be contacted in case of an emergency *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Relationship *

Phone Number *

Physician Name *

Physician Phone Number *

Does your child have any special medical needs? *

Yes No

If yes, please specify *

General Release of Liability:
In consideration of being allowed to participate in any way in the Program and related events and activities the undersigned
agrees to the following: I acknowledge and fully understand that each participant will be engaging in online activities that
may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result
not only from their actions, inactions or negligence, but the action, inaction or negligence of others, the rules of play or the
condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably
foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question.
I understand that the Duval County School Board, the Kids Hope Alliance and the selected community based organization
and their employees and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in
activities through the Program. I agree to hold the Duval County School Board, the Kids Hope Alliance and the selected
community based organization and its employees and agents harmless from any and all liability, which may arise while
exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of
property that may occur to my daughter/son while participating in the Virtual Summer Camp Program.

Authorization for Emergency Care:
In case of accident or serious illness, and the school/program is unable to reach me, I hereby authorize the school/program to
contact the physician indicated on the application and to follow his/her instructions: If it is impossible to contact this
physician, the school may make whatever arrangements necessary to provide care and treatment for my child.
In case of accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain
at school, the school/program will contact me or arrange transportation for my child. If the school/program is unable to reach
me, I authorize the school/program to contact one of the persons indicated on the enrollment form.

Photo/Media Release:
I acknowledge and understand that publicity activities such as interviews, photos, and videotaping may occur. I consent and
permit my child, as a participant in the Summer Camp Program and events, to be photographed, videotaped, and/or
interviewed for publicity activities.

Photo/Media Release *

Yes No

Parent/Guardian's Signature and Date of Signing *

School Records Release Statement
I give my consent for my son’s/daughter’s/ward/’s school records to be accessed by the selected community based
organization and the Kids Hope Alliance through the Duval County Schools Student Information Management System
(SIMS) for the purpose of gathering data for analysis of program effectiveness. The data accumulated will be aggregated
without identifying any individual child.

Parent/Guardian is responsible for connecting the devices to virtual classroom daily.
Failure to comply may result in participant being removed from the program.

Does your child have health insurance? *

Yes No

Would you like to be contacted by someone from the Kids Hope Alliance/Cover Jacksonville with more information about KidCare coverage for children under 19? *

Yes No

(Application is not considered complete unless signed below to indicate agreement with all of the above.) Student and parent/guardian signatures and date of signing: *

Dear Parent/Guardian:
To assist in ensuring your child’s well-being while attending Summer Camp Program, please complete and return
immediately.

STUDENT HEALTH FORM

Parent/Guardian Name *

First

Last

Home Phone Number *

Cell/Work Phone Number *

Student Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact Name *

First

Last

relationship *

Home Phone Number *

Work/Cell Phone Number *

Submit

Youth S.T.E.A.M. Camp Application 2020 Page 2

Check any of the following that your child is being treated for *

Diabetes Asthma Epilepsy or seizures Hemophilia or other bleeding disorder Other

If other, please specify *

* Indicates required field

Does your child have a history of chronic illness? If so, please specify. *

Does your child have any allergies? If so, please specify. *

Authorization for Emergency Care:
In case of accident or serious illness, and the school/program is unable to reach me, I hereby authorize the school/program to contact the
physician indicated on the application and to follow his/her instructions: If it is impossible to contact this physician, the school may make
whatever arrangements necessary to provide care and treatment for my child.
In case of accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain at school, the
school/program will contact me. If the school/program is unable to reach me, I authorize the school/program to contact one of the persons
indicated on the enrollment form.

Parent/Guardian Signature and Date of Signing *

Sibling Notification Form: (this form helps us identify siblings for program placement.)

date *

Parent Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell/Work Phone Number *

Student ID #'s, names, schools, and grade levels of the student's siblings (listing siblings on this form does not constitute an enrollment application for that student. A separate form will need to be filled out for each participant.) *

Please submit both pages of the form.

Submit

Please submit both pages of the form.

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* Indicates required field

Email *

I am a(n) *

Parent/Caregiver Student Educator Other

I am interested in *

Summer Camp Virtual Classes After School Programs Field trips Summer VPK

What is the current school grade of your student? *

I agree to receiving marketing and promotional materials

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