Girl's Full Name *

First Name

Last Name

Pronouns *

she/her

they/them

he/him

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Preferred form of communication *

Call

Email

Text

WhatsApp

Caregiver 1: Full Name *

First Name

Last Name

Caregiver 1: Pronouns *

she/her

they/them

he/him

Caregiver 1: Relationship to Child *

Caregiver

Mother

Father

Legal Guardian

Caregiver 1: Phone Number *

(###)

###

####

Caregiver 1: Preferred form of communication *

Call

Email

Text

WhatsApp

Caregiver 2: Full Name

If applicable

First Name

Last Name

Caregiver 2: Pronouns

If applicable

she/her

they/them

he/him

Caregiver 2: Relationship to Child

If applicable

Caregiver

Mother

Father

Legal Guardian

Caregiver 2: Phone Number

If applicable

(###)

###

####

Caregiver 2: Preferred form of communication

If applicable

Call

Email

Text

WhatsApp

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1: Pronouns *

she/her

they/them

he/him

Emergency Contact 1: Relationship to Child *

Caregiver

Mother

Father

Legal Guardian

Emergency Contact 1: Phone *

(###)

###

####

Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2: Pronouns *

she/her

they/them

he/him

Emergency Contact 2: Relationship to Child *

Caregiver

Mother

Father

Legal Guardian

Emergency Contact 2: Phone *

(###)

###

####

Do you grant permission for your girl to be dismissed without a caregiver?* *

Yes

No

If not, who do you anticipate will pick-up your girl(s)?*

Myself (Caregiver 1)

Caregiver 2 or Emergency Contact(s)

Race and Ethnicity *

African

African-American

Black

Caribbean

Latine

Other

Gender *

Cis

Femme

Girl

Trans

Non-Binary

Does your girl have any chronic medical conditions? Check all that apply. *

Allergies

Anxiety

Asthma

Depression

Diabetes

Epilepsy

Other

Does your girl have any environmental allergies (e.g., pollen, dust)? *

Yes

No

Does your girl have any food allergies? *

Yes

No

Is your girl currently taking any medications? *

Yes

No

Primary Care Provider Full Name

First Name

Last Name

Primary Care Phone *

(###)

###

####

Primary Care Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Consent *

I authorize Love Your Magic staff and its designated affiliates and representatives that are trained in the basics of first aid to give my child first aid and/or CPR when appropriate. As part of Love Your Magic programming, I understand my child may participate in a variety of physical activities. I understand that Love Your Magic recommends that my child consult a physician before engaging in physical activity, and, if my child’s physical health is questionable, that we obtain medical clearance from a licensed medical professional. I also understand that I am fully responsible for my child’s medical expenses, including deductibles, co-pays, and transportation. I understand that Love Your Magic will make every effort to contact me in the event of an emergency requiring medical attention for my child. However, in the event that I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and I consent to emergency medical treatment for my child if Love Your Magic, in its sole discretion, determines it to be necessary.

I agree

Promotional Release *

From time to time, Love Your Magic is highlighted in newspaper articles, press releases, videos, or on the Love Your Magic website. These publications often involve photos, videotaping, or other types of recording. This form requires your permission for your child to be included in such works. I, the parent or guardian identified below, hereby grant Love Your Magic the irrevocable and unrestricted right to spontaneously photograph, videotape, or tape record my child while in attendance in the Love Your Magic Summer Camp for advertising, promotion, or other lawful purposes at any time. I give Love Your Magic the right to alter said photographs and other media works without restriction and to copyright the same in their name. I acknowledge and agree that I will not be contacted to inspect or approve the finished product, and that the finished product may or may not be available to me. I hereby release and hold harmless Love Your Magic from any damages or liability relating to or arising from any use of the images, videos, or recordings. I waive any claim I may have based on any use of the images or works derived therefrom. I understand that Love Your Works would not use such media without first receiving a copy of this release signed by me, as set forth below. I represent and warrant that I have read this release and am familiar with its contents.

I agree