Summer Youth Program Registration is now open.

$25.00 Early Registration Fee May 1st – May 31st.

Beginning June 1st registration is $50.

$150 weekly donation.

The registration fee includes 1 T-shirt.

Complete the registration form to GET STARTED!!

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Child's Name *

First

Last

Gender *FemaleMale

Age *

As of June 1st

Phone *

Mobile/Home

Grade *

School Name *

School Address

PARENT INFORMATION

Please complete all the information requested, if not applicable mark N/A

Parent/Guardian Name *

First

Last

Phone *

Mobile/Home

Email *

Address *

Town/City State Zip Code

Employment Information *

Employer and Occupation

Parent/Guardian Name *

First

Last

Email *

Address *

Town/City State Zip Code

Employment Information *

Employer and Occupation

Emergency Contact Information

2 emergency contacts are required

Emergency Contact *

First

Last

Phone *

Mobile/Home

Email *

Address *

Town/City State Zip Code

Relation to child *

Emergency Contact *

First

Last

Phone *

Mobile/Home

Email *

Address *

Town/City State Zip Code

Relation to child *

Child lives with *

Person responsible for payment *

Alternate Release Information

Please provide the names of people in addition to parents/guardians who are permitted to pick up your child below

Name *

First

Last

Name *

First

Last

Name *

First

Last

Medical Release Information

Please complete required fields below. Mark N/A if necessary

Insurance Provider *

Policy Number *

Primary Physician *

Hospital Preference

Hospital Phone Number

Hospital Address

Medical History *

Please list any medical problems, including any requiring maintenance and or medication (i.e. Diabetic, Asthma, Seizures)

Required Medication/Maintenance *

i.e. Inhalers, specific medication

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *YesNo

Parents Initials *

I understand that A Place wit Nia Youth Program will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *YesNo

Do you consent for the paramedics to be called to treat your child in case of emergency?

Parents Initials *

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *YesNo

If yes, explain below *

Is your child allergic to any type of food or medication? *YesNo

If yes, explain below *

Does your child require a special diet? *YesNo

If yes, explain below *

Please list any special dietary needs.

How did you heard about the A Place wit Nia Youth Program /Summer Explorer Camp. *

• After School Program
• Website
• Word of Mouth
• Flyer
• Other

T-Shirt Size *Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult Large

Additional shirts can be purchased for $10.00

Terms of Agreement and Photo Release

Please read terms and photo release info to the end and initial

I hereby give permission for my child to be photographed during the A Place wit Nia Summer Explorer Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of A Place wit Nia Youth Program / Summer Explorer Camp. *I understand

Parents/Guardian Initials *

A Place wit Nia Youth Program and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). *I understand

Parents/Guardian Initials *

Printed Signature of Parent/Guardian* *

First

Last

*My printed name here is acting in place of a signed signature

Date *

mm/dd/yyyy

A Place Wit Nia Registration Fee *

Price: $50.00

The $50.00 registration fee includes 1 T-shirt.

Stripe Credit Card *

Submit

Camp Schedule: Mon -Fri 9am-4pm

Make Checks Payable to: A Place wit Nia Youth Program (include Childs name on memo)

aplacewitnia@gmail.com

Los Angeles, Ca 90018