Camper Information Form - Summer Camps | Central Piedmont Youth Central

Completing all required forms secures your child’s spot in their registered camp(s). Campers with incomplete information will not be permitted to attend camp(s).

* Indicates required field

Student Name *

Birth Date *

Rising Grade *

Camp Attending *

Session Start Date *

Legal Parent/Guardian First Name *

Legal Parent/Guardian Last Name *

Email *

* Email should be an active and monitored address as all camp communication will be sent here.

Legal Parent/Guardian Phone *

Secondary Phone *

Student Release

If your student is of an independent age and able to safely leave the building on his or her own, you may give your student permission to sign in and out of the class personally. *Once the student leaves the class, we cannot be held responsible for his or her safety nor behavior.

Release Permission

Yes, I give permission for my student to sign himself/herself out of class each day.

No, I do NOT give permission for my camper to sign himself/herself out.

Student Transportation/Pick-up

Please list anyone, other than yourself, who may be picking up your student. Proper identification must be shown.

Name *

Phone

Relationship to Student

Name *

Phone

Relationship to Student

Medical History & Authorization - Required

Your child's safety and well-being are the top priority for us. In case of emergency, this information will assist us in providing the care your child may need.

Primary Physician Name *

Phone *

Address *

Preferred Hospital *

Insurance Carrier *

Policy Number *

Group Number *

Policy Holder's Name *

Medical Condition (check all that apply)

ADD/ADHD

Allergies - Environmental

Allergies - Food

Asthma

Diabetes

Epilepsy/Seizures

Heart Disease

Other

Additional information regarding medical conditions, including specific allergies (i.e. Dairy Allergy)

I agree to pay for any and all medical expenses incurred and grant permission to the physician or health care professional to provide medical care if and when necessary. *

I agree

If your child takes medication, you are required to complete the Medical Authorization Form as part of your registration. CPCC Youth Central staff are prohibited from administering any medication. Your child is must to be able to administer medication to themselves (i.e. EpiPen, insulin, etc.).

Emergency Contacts - Required

Contacts must be someone other than parent/guardian.

Name *

Phone *

Relationship to Student *

Name

Phone

Relationship to Student

We Capture Your Student's Smiles

We often take photographs and videos of our camps in action for our promotions, advertising, and many other uses. We need your consent on file if you would like to give us permission to use your student's image for our publications.
1. The photographs may be used by the College (i) in or as instructional materials, (ii) in catalogs, brochures and other information about the College, (iii) in advertising, or (iv) for publication or use for any other purpose deemed proper by the College.
2. I waive any right to inspect or approve the finished product or advertisement or the particular use made of the photographs.
3. The photographs may be modified or retouched in any way the College considers desirable.
4. I release the College and its agents from any liability by virtue of any blurring, distortion, alteration, misnaming or mislabeling, whether intentional or otherwise, that may occur, provided that these things are not maliciously done solely for the purpose of subjecting me to ridicule or scorn.

Photography Consent *

I consent to photographs, motion pictures, or videotapes (collectively referred to as "photographs") being taken of my student by persons acting with the permission and on the authority of Central Piedmont Community College (the"College") and authorize their use under the above conditions.

DO NOT PHOTOGRAPH. I do not give permission for my student's photo to be taken.

Student Code of Conduct

Students enrolling in Central Piedmont's Summer Camps assume an obligation to conduct themselves in a manner compatible with the college's function as an educational institution. Misconduct of students and parents fall into the following categories:
1. Dishonesty: knowingly giving false information to or withholding vital information from Central Piedmont Services Corp staff or faculty.
2. Behavior: indecent, violent, or harassing behavior that disrupts the classroom environment or requires action on part of staff or faculty.
3. Use of property and technology: theft, damage, or destruction of any technology, equipment, or property of the college or its staff or faculty.
4. Dress Code: not adhering to the strictly defined dress code of the specific camp

Failure to comply with the above expectations will result in disciplinary actions as follows:
1. Warning: Parents/guardians will be notified of the behavior infraction in person or in writing, and the student will be addressed about the action.
2. Dismissal: If the behavior continues, the parents/guardians will be contacted to immediately remove student from session, and the student will be terminated from any future Central Piedmont Summer Camp enrollments. Refunds will not be given for dismissal.

Parent Permission

Check each statement to indicate your agreement. *

I give permission for my student to participate in Central Piedmont Youth Central Programs.

I will assure my student complies with the Student Code of Conduct and will behave accordingly while at camp.

I will be responsible for assuring my student arrives on time and is picked up promptly. I understand that the Central Piedmont Services Corp staff and faculty are not responsible for my child once camp ends.

I and my student have read the above policies and agree to them.

Special Accomodations

Central Piedmont Community College is committed to providing an accessible education and supportive learning environment for all students. Students with disabilities who require special accommodations must notify Central Piedmont Services Corporation, in writing, two weeks before the camp begins, so that accommodations can be arranged. All information will be kept confidential. Central Piedmont Community College does not provide personal medical assistants or care attendants.

Liability Release

Agreement of Terms *

I hereby grant permission for my child to take part in this program sponsored by Central Piedmont Community College Summer Camps or Teen Coding. I believe the information provided above is a complete and accurate statement of the physical and behavioral factors which may affect my child's participation in this summer camp sponsored by Central Piedmont Community College Summer Camps or Teen Coding. I also agree, on behalf of myself or my child, not to make any claims of any kind against the Central Piedmont Community College Summer Camps, Central Piedmont Community College Teen Coding, Central Piedmont Community College, or any of its employees or agents for any loss or injury that my child might sustain while engaged in the summer camp program. I authorize such physician or medical staff as the Central Piedmont Community College Summer Camps, Central Piedmont Community College Teen Coding and staff of Central Piedmont Community College may designate to carry out any minor treatment and/ or medical staff to provide any treatment deemed necessary for well being of my child.

Full Parent/Guardian Name