Please complete this form prior to your student's session start date. Your student will not be allowed into the session without our receipt of your completed student and medical forms .

* Indicates required field
Student Name *
Birth Date *
Rising Grade *
Camp Attending *
Session Start Date *
If your student is attending more than one camp, please select all additional camps attending.
Parent/Guardian First Name *
Parent/Guardian Last Name *
Email *
Preferred 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

Student Transportation/Pick-up

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

Name *
Relationship to Student
Name *
Relationship to Student

Emergency Medical Authorization - Required

Primary Physician Name *
Phone *
Address *
Preferred Hospital *
Insurance Carrier *
Policy Number *
Group Number *
Policy Holder's Name *
Medical Condition (check all that apply)
Additional Information Regarding Medical Conditions

Emergency Contacts - Required

Contacts must be someone other than parent/guardian.

Name *
Phone *
Relationship to Student *
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 *

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. *

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 *
Full Parent/Guardian Name