2017 Creativity Camp Membership Application

Please complete the form below

STUDENT INFORMATION
Student's Name *
Student's Name
Birthdate *
Birthdate
Gender *
T-Shirt Size *
PARENT INFORMATION
Name *
Name
Address *
Address
Cell Phone *
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Does your family receive services from the Chicago Housing Authority (CHA) or Department of Children and Family Services (DCFS)? *
If yes, please provide the following:
MEDICAL HISTORY
Any allergies/illnesses? *
(If your child has to be administered any medications, they must be prescribed by a medical physician and/or has to be sent in a secure bottle with specific administering instructions)
EMERGENCY CONTACT
Name 1 *
Name 1
Phone 1 *
Phone 1
Name 2
Name 2
Phone 2
Phone 2
AUTHORIZED RELATIVES/FRIENDS
Name 1 *
Name 1
Name 2
Name 2
PARENTAL CONSENT
During the time your child is enrolled in our program, he/she will be involve in various activities that require permission or consent. Please read the following information thoroughly and ask LBP staff any questions you may have regarding this information. You may choose to not give permission at your discretion.
1. The area and location of field trips are fully confidential between parents and staff. No child will be able to participate in field trips without the written consent of a parents or guardian. I understand all such trips are under the supervision of Little Black Pearl staff and interns, and that health and safety precautions are our first priority. *
2. We periodically photograph, videotape and audiotape program participants for broadcast and promotional purposes beneficial to the growth of the organization. No royalties or compensation will be provided in such instances. *
3. Permission for Little Black Pearl to administer first aid to your child, or if necessary, transport child to receive emergency care for minor cuts and/or abrasions. Parents will always be contacted first. *
4. Permission to be transported by insured vehicles owned or leased by Little Black Pearl. *
5. I understand and agree that as parent or guardian that if my child is found to have been involved in the theft, destruction, or vandalism of any property own or operated by Little Black Pearl, its staff and students, I can be held financially liable. *
BY SUBMITTING THIS FORM I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE. I AUTHORIZE LITTLE BLACK PEARL (LBP) TO USE THE INFORMATION PROVIDED TO CONSIDER MY CHILD FOR A SUMMER CAMP ADMISSION. I ALSO AUTHORIZE LBP TO VERIFY ALL INFORMATION ON THIS FORM.