Little Jack Rec Camp
Registration Form
Family's Last Name:
Please select one:
SFA Faculty
SFA Staff
SFA Student
CID#:
Campus Rec Member
Member Name:
Non-SFA/Nacogdoches Community
Alumni Association Member
Child Name:
Age:
Gender:
Male
Female
Age Group Requested:
5-7 Years Old
8-9 Years Old
10-12 Years Old
Check the sessions you wish to enroll your child in:
Session #: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
6/6 - 6/10
Dates:
Check Here:
6/13 - 6/17 6/20 - 6/24
Child Name:
6/27 - 7/1
7/11 - 7/15 7/18 - 7/22 7/25 - 7/29
Age:
Gender:
Male
8/1 - 8/5
Female
Age Group Requested:
5-7 Years Old
8-9 Years Old
10-12 Years Old
Check the sessions you wish to enroll your child in:
Session #: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
6/6 - 6/10
Dates:
Check Here:
6/13 - 6/17 6/20 - 6/24
Child Name:
6/27 - 7/1
7/11 - 7/15 7/18 - 7/22 7/25 - 7/29
Age:
Gender:
Male
8/1 - 8/5
Female
Age Group Requested:
5-7 Years Old
8-9 Years Old
10-12 Years Old
Check the sessions you wish to enroll your child in:
Session #: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
6/6 - 6/10
Dates:
Check Here:
6/13 - 6/17 6/20 - 6/24
6/27 - 7/1
7/11 - 7/15 7/18 - 7/22 7/25 - 7/29
8/1 - 8/5
Additional offerings per session (not included in registration cost): Early Drop Off: $10 Late Care: $20
Session #: Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
Early Drop:
Late Pickup:
Will all children need these services?
Y
N
Office Use Only
SFA Student, Faculty, Staff, Alumni or Rec Center Member - $155/week per child
# of Sessions Reg:
Non-SFA or Community member - $180/week per child
# of Discounts Given:
Total Amount Owed:
Payment Record:
Payment #1:
Date:
Payment Form:
Cash
Payment #2:
Date:
Payment Form:
Cash
Payment #3:
Date:
Payment Form:
Cash
CSI #:
Check#:
Credit/Debit
CSI #:
Check#:
Paid in Full or Amount Remaining:
Received by:
Credit/Debit
CSI #:
Check#:
Received by:
Paid in Full or Amount Remaining:
Received by:
Credit/Debit
Paid in Full or Amount Remaining:
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Little Jack Rec Camp
Camper Information Form
Child Name:
Age:
DOB:
Gender:
Returning from a previous summer?
Can participate in free swim if they choose?
Registered for swim lessons?
Y
Y
N
N
Y
Male
N
Female
Summer(s):
Rock Climbing?
What dates?
Y
N
AL
AXL
Time?
Camper requests to be grouped with the following campers:
Camper Shirt Size: YS (6-8)
Medical Information:
YL (14-16)
YM (10-12)
AS
AM
Please list any conditions to which we should be aware.
Child Name:
Age:
DOB:
Gender:
Returning from a previous summer?
Can participate in free swim if they choose?
Registered for swim lessons?
Y
Y
N
N
Y
Male
N
Female
Summer(s):
Rock Climbing?
What dates?
Y
N
AL
AXL
Time?
Camper requests to be grouped with the following campers:
Camper Shirt Size: YS (6-8)
Medical Information:
YM (10-12)
YL (14-16)
AS
AM
Please list any conditions to which we should be aware.
Child Name:
Age:
DOB:
Gender:
Returning from a previous summer?
Can participate in free swim if they choose?
Registered for swim lessons?
Y
N
Y
N
Y
Male
N
Female
Summer(s):
Rock Climbing?
What dates?
Y
N
AL
AXL
Time?
Camper requests to be grouped with the following campers:
Camper Shirt Size: YS (6-8)
Medical Information:
YM (10-12)
YL (14-16)
AS
AM
Please list any conditions to which we should be aware.
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Little Jack Rec Camp
Parent/Guardian Information Form
In the event of an emergency, please list the name of the person we should contact first:
Parent/Guardian Info:
Parent 1:
Parent 2:
Contact #:
Contact #:
Email:
Email:
Parent/Guardian Mailing Address:
Please tell us how you heard about our camp:
Emergency Contacts:
Please list two non-parent contacts that will be able to pick up if necessary.
Name:
Name:
Contact #:
Contact #:
Relationship:
Relationship:
Camper Release Authorization
Please list names of people (other than listed above) who HAVE permission to pick up your children:
Name:
Name:
Contact #:
Contact #:
Name:
Name:
Contact #:
Contact #:
Name:
Name:
Contact #:
Contact #:
*Parents, emergency contacts, and the individuals listed above are the only individuals permitted to pick up your
children from camp! If an individual is not on this list, they will not be allowed to pick up your children. Any
additions or deletions to this list must be done in person. ANYONE PICKING UP YOUR CHILDREN MUST
SHOW A DRIVERS LICENSE.
Please list anyone WHO DOES NOT have permission to pick up your children.
Physician's Name:
Phone Number:
What is your CODE WORD for us to use to identify you over the phone?
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Little Jack Rec Camp
Medication Authorization Form
AUTHORIZATION TO ADMINISTER MEDICATION
The Department of Campus Recreation WILL NOT administer medication to participants. The following
authorization form is to be completed if alternative arrangements are to be made.
Parent/Guardian Name:
Contact #:
If I am not available to administer medication, the following person(s) are authorized to administer any needed medications.
Contact Name:
Contact #:
Contact Name:
Contact #:
Physician's Name:
Contact #:
Child's Name:
Dosage:
Medication:
Dosage Time(s) to be Adminstered:
Possible Side Effects:
Special Instructions:
Child's Name:
Dosage:
Medication:
Dosage Time(s) to be Adminstered:
Possible Side Effects:
Special Instructions:
Child's Name:
Dosage:
Medication:
Dosage Time(s) to be Adminstered:
Possible Side Effects:
Special Instructions:
Prescribed medication shall be given to a child only in accordance with the parent/guardian's written consent through this form.
Parent/Guardian Signature:
Date:
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