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 residents between the ages of 5 and 12 or be prior participants in HFKC. Please clearly print all information except signatures.
Child’s Name ___________________________________ Age _______ Gender: Male Female
Child’s Social Security Number ____________________________ Birth Date _______________
Home address: Street ______________________ 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 ( ) ________________
Cell phone ( ) __________________ *Email address _________________________
Required: 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
Is there someone else you’d like to add to this list? Name ________________ Cell ______________
Registration cost (non refundable) $20.00 for only one child or $30.00
per family.
Cost is $50.00 weekly for each camper
Please include payment with registration.
Has your child ever been registered for HFKC before? Yes No
My child will attend (check one): All day Half Day Two weeks the entire session
Name of other campers from same household:
_________________________________________
_________________________________________
_________________________________________
☐
Please provide a copy of your child’s current report card.
From time to time, our camp receives press from area media. If you consent to having your child included in any printed images, please initial. __________________
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 arrange for that supervision.
Signature of Parent _________________________________

❑ 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 there are any questions or if further information is needed.
Has your child had any of the following?
YES NO
1 Allergies?
Food(s)
Bee stings/ Insect Bites
Medications
1a.
Does your child have an epipen?
Has your child had any of the following?
1b.
2
Does your child need Benadryl?
Asthma/ Wheezing?
2a.
Has your child have an asthma inhaler?
2b.
3
4
How frequently?
Nose bleeds?
Hemophilia?
Diabetes?
Bleeding Disorder?
Sickle Cell Anemia?
5
6
Heart Problems?
Chest Pain?
7
8
Convulsions
Does your child take any daily medications? If yes, please list meds.
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 Medical Center ____ 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, it will be necessary to have your child’s pediatrician 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:
_________________________________________________________________________

Health Insurance Information
Does child have health insurance? Yes No If yes, is it HUSKY? Yes/ No (For HUSKY call 1-877-CTHUSKY)
Name of Insurance Comp. 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 Emergency Contact Name ______________________________
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.

Child’s First Name _________________________M.I. ______ Last Name__________________
Address ______________________________________________ Zip Code ________________
City : Hartford/ East Hartford/ Other ____________________
Gender ______ Date of Birth ______________________
Last School Attended _______________________Grade your child is entering _______________
Does your child have any special needs? _________ If yes, what? _________________________
_______________________________________________________________________________
_______________________________________________________________________________
Check below
American Indian or Native American
Black or African American
Jamaican
Puerto Rican
White
Other
Parent (or Guardian’s) Signature _____________________________________
Telephone or Cell Contact __________________________________
Email Address ___________________________________________