Summer Overnight Program for Springfield Students
June 28 - July 2, 2027
AGES: 10 - 15
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TRANSLATE THIS FORM: Español, Português, Française, Kiswahili, Tiếng Việt, Tagalog, Kreyòl ayisyen
FOR WHOM?
I AM A PARENT OR GUARDIAN
REGISTERING A NEW CHILD/MINOR TO PARTICIPATE
YOUR (PARENT/GUARDIAN) NAME:
YOUR (PARENT/GUARDIAN) CONTACT INFORMATION:
NAME:
(not parent)
CONTACT INFORMATION:
(OPTIONAL)
BIRTHDATE:
Please enter a valid birthdate here...
GENDER:
Please enter a gender information here...
use button or write in anything!
Male
Female
Non-Binary
PRONOUNS:
use button or write in anything!
He/Him/His
She/Her/Hers
They/Them/Theirs
LANGUAGE:
(only if not English)
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HOUSEHOLD/FAMILY DETAILS:
PARTICIPANT MAILING ADDRESS:
* ONLY IF OUTSIDE OF USA
YOU MAY ENTER ONE OR TWO RELATED ADULTS
WHO LIVE or WORK AT THIS ADDRESS:
ADULT #1
(optional)
parent, step-parent, guardian, spouse, etc.
(optional)
ADULT #2
(optional)
parent, step-parent,
guardian, spouse, etc.
(optional)
I WANT TO INCLUDE ANOTHER ADULT/PARENT/GUARDIAN AT A DIFFERENT ADDRESS
OTHER ADULT
(optional)
parent, step-parent, guardian, spouse, etc.
(optional)
OTHER MAILING ADDRESS:
* ONLY IF OUTSIDE OF USA
SUBMIT ADULT CONTACT INFORMATION
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PERSONAL INTRODUCTION
TELL US ABOUT YOURSELF:
TELL US ABOUT YOUR CHILD:
What specifically interests you in this program?
What other interests / hobbies / activities do you enjoy?
What specifically interests your child in this program?
What other interests / hobbies / activities do they currently enjoy?
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IMPORTANT DETAILS:
DIET:
NONE
Please describe any special dietary restrictions, and indicate whether they result from personal preference, religious custom, or medical necessity.
ALLERGIES:
NONE
Any ALLERGIES?
To foods? To medications? To insect stings or other environmental agents?
If so, please explain the symptoms and the severity of these allergies: ( MILD DISCOMFORT or SEVERE LIFE THREATENING ANAPHYLAXIS )
MEDICATIONS:
NONE
Any regular MEDICATIONS? If so, please list the medications, their dosage and frequency, and their purpose. This information may be used to administer medications during a program, but more importantly it will help medical professionals in the event of an emergency.
CONCERNS:
NONE
Tell us any concerns you may have about participation in our programs: Any
injuries or physical limitations
, or any
emotional, behavioral, or mental health issues
, any
sleep issues
,
substance abuse
, history of
infections
, or anything else that you can let us know in advance to help our staff to make the program safe and enjoyable for everyone.
Please note: failure to disclose significant medical or learning issues undermines our work and the safety of our programs, and we reserve the right to dismiss any participant who arrives with undisclosed conditions.
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ALMOST DONE, KEEP GOING!
PLEASE COMPLETE THIS VALIDATION:
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