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Hartford Friendship Kids’ Camp REGISTRATION
All forms must be completed and signed by a parent or guardian for it to be accepted. Children
eligible for registration must be Hartford or East Hartford residents between the ages of 5 -12.
Please clearly print all information except signatures.
Child’s Name ____________________________ Age _____ Gender: Male ---- Female ----Child’s Social Security Number ____________________________ Birth Date _____________
Home address: ______________________ Hartford, East Hartford, CT/Zip Code ___________
School Name __________________________________ Grade Completed in June _______
Parent/ Guardian’s Full Name ______________________________ SS# __________________
For demographic purposes, the head of our household is Male _____Female _____
Home phone (860) _________________
Work Phone (860) ________________
Cell phone ( ) __________________ *Email address _________________________
If parent/ guardian cannot be reached in case of emergency, please notify:
Full Name ________________________________________ Phone (
) ________________
Can your child be released from HFKC to this person in case of emergency or illness? Yes No
Registration cost (non refundable) $20.00 for only one child or $30.00 per family. Cost is $50.00
weekly for each camper. Include payment with registration.
1. Has your child ever been registered for HFKC before? Yes
No
2. Is your child required to attend summer school? Yes
No
3. My child will attend (check one): All day
Half Day
Two weeks
Entire session
Name of other campers from same household:
_____________________ _____________________ _____________________
☐ Please provide a copy of your child’s current report card.
☐ I hereby give my permission for the above named child to be transported to and from
sponsored activities by authorized and licensed personnel of the HFKC. I also understand that
should my child present a severe behavioral problem or seriously violate any trip rules, I will be
notified and arrangements will be made to send the child home. If your child requires 1 – on – 1
supervision, you’ll need to arrange for that supervision.
Signature of Parent ________________________
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❑ My child’s immunization shots are up to date.
❑ I have provided proof of the same.
Please complete the questionnaire below, providing information that will help to safeguard your child.
Our staff will review the information and be in touch with you if further information is needed.
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Has your child had any of the following?
Allergies?
Food(s)
Bee stings/ Insect Bites
Medications
Does your child have an epipen?
Has your child had any of the following?
Does your child need Benadryl?
Asthma/ Wheezing?
Has your child have an asthma inhaler?
How frequently?
Bleeding Disorder?
Nose bleeds?
Sickle Cell Anemia?
Hemophilia?
Diabetes?
Heart Problems?
Chest Pain?
Convulsions
Does your child take any daily
medications? If yes, please list meds.
YES
NO
If you answered “yes” to any of the above questions or your child has any other medical conditions,
please explain below.
___________________________________________________________________________________
___________________________________________________________________________________
__________________________
Child’s Doctor/ Clinic _____________________________ Telephone # _________________________
Hospital of choice: ___ Hartford Hospital ___ St. Francis ___ UCONN ___ Other _________________
Does your child have any medical problems, operations, injuries or special restrictions? Yes ___ No ___
If yes, explain ________________________
*If medications need to be administered by staff during the camp day, your child’s pediatrician must
complete a form.
List any major illnesses in the last year __________________________________________________
Does your child have any special needs / disabilities that require extra adult supervision? If yes, please
explain: ___________________________________________________________________________
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Child’s Name ______________________________________
Health Insurance Information
Does child have health insurance? Yes No If yes, is it HUSKY? Yes/ No (For HUSKY call 1-877CTHUSKY)
Name of Insurance Company. if child is NOT covered by HUSKY Insurance or Medicaid _____________
Client ID No. _________________________
I, __________________________, the parent and /or legal guardian of __________________, a minor
child, hereby acknowledge that my child is presently under my care, custody and control. I hereby give
my child express permission to participate in the activities at the Hartford Friendship Kids’ Camp. I also
give my permission to the Hartford Friendship Kids’ Camp, its staff persons and its representatives, or
any attending physician, to make decisions and perform such medical treatments and/or surgery upon
my child, which may in their sole discretion be necessary and proper under the circumstances. I do
release and covenant to hold harmless HFKC, its agents and employees from any and all damages or
liabilities arising out of any sickness or injury incurred by my child during camp.
To the best of my knowledge, the above information is complete and accurate.
Date ____________ Parent’s Signature _______________________ Telephone # _____________
Important:
We are always looking for ways that parents can be involved in the education of their children in the
home. Our aim is to form a vital link between the camp and the home. In this way, your child is more
prepared to excel during the school year. If there is a way that you can assist us in the process, please
let us know. If any opportunities arise where we think you can assist us here at HFKC, please do not be
surprised if we call on you. As you know, it takes a village!
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HFKC Camper Intake Form to Determine Demographics
Child’s First Name _________________________M.I. ______ Last Name_________________
Address ______________________________________________ Zip Code ______________
City : Hartford/ East Hartford/ Other ____________________
Gender ______ Date of Birth _____________ Age _______
Last School Attended _______________________Grade your child is entering _____________
Does your child have any special needs? ______ If yes, what? _________________________
____________________________________________________________________________
____________________________________________________________________________
Race or Ethnicity
Check below
American Indian or Native American
Black or African American
Jamaican
Puerto Rican
White
Other
Photo Release
I hereby agree that all photographs, negatives, prints, paintings, drawings, sketches,
reproductions and likeliness of any kind made of the child are and shall remain the property of
the Hartford Friendship Camp. I give my permission that said works may be published, displayed,
reproduced and circulated in any form by Hartford Friendship Camp with or without the child’s
name for commercial purposes or otherwise, including advertisement in any media and with or
without any testimonial copy or other form of advertising or display.
Parent (or Guardian’s) Signature _____________________________________
Telephone or Cell Contact
Email Address
__________________________________
______________________________________
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