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 and 12. 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, 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
Registration cost - $20.00 for only one child or $30.00 per family.
Cost is $60.00 weekly for each new camper *Possible discount for 2012 campers
Please include payment with registration.
Has your child ever been registered for HFKC before? Yes
No
My child will attend: ☐All day ☐Half Day ☐1 week ☐2 weeks ☐3 weeks ☐4 weeks ☐5 weeks
Name of other campers from same household:
_________________________________________
_________________________________________
_________________________________________
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 _________________________________
Camper’s Name __________________________________________ Date of Birth ___________
Parent’s Name____________________________Email address ___________________________
Address ________________________________ Telephone ___________Cell ________________
❑ 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.
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1a.
1b.
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2a.
2b.
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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?
YES
NO
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.
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 Hosp _____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 Company if child is NOT covered by HUSKY Insurance, HUSKY 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 # ________________________
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 ______________________
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
Parent (or Guardian’s) Signature _____________________________________
Telephone or Cell Contact __________________________________
Email Address ___________________________________________