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
First Name *
Last Name *
Birth Date *
Rising Grade *
If your student is attending more than one camp, please select all additional camps attending. *
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 Transportation/Pick-up

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

First Name
Last Name
Phone
Relationship to Student
First Name
Last Name
Phone
Relationship to Student

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 *

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

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, three 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.



 

Medication and Medical Care Policy

If your child requires medication, you must complete the Medical Authorization Form as part of the registration process. Please note that CPCC Youth Central staff are not permitted to administer any medication. Your child must be capable of self-administering their own medication (e.g., EpiPen, insulin).

I understand that CPCC Youth Central staff are prohibited from administering medication and that my child is responsible for self-administering any required medication.

I agree to be responsible for any and all medical expenses incurred and grant permission to a physician or healthcare professional to provide medical care to my child if and when necessary.

I confirm that I have adequate health insurance to cover any medical costs that may result directly or indirectly from my child's participation in this program. I further agree to pay for any medical expenses that exceed the limits of my insurance coverage. 

I confirm that the information provided about my child's health and behavior is accurate and complete.

I authorize any physician or medical personnel designated by Central Piedmont Community College Summer Camps, Central Piedmont Community College Teen Coding, or other CPCC staff to provide any treatment deemed necessary for the health and well-being of my child, including minor medical care and emergency treatment if needed.

I have read and understand the Medication and Medical Care Policy for CPCC Youth Central. I authorize and agree: *

Emergency Contacts - Required

Contacts must be someone other than parent/guardian.

First Name *
Last Name *
Phone *
Relationship to Student *
First Name
Last 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 *