Girl's Full Name
*
First Name
Last Name
Nickname or preferred name?
Pronouns
*
Date of Birth
*
MM
DD
YYYY
Grade In School
*
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
(###)
###
####
Email
Preferred form of communication
*
Caregiver 1: Full Name
*
First Name
Last Name
Caregiver 1: Pronouns
*
Caregiver 1: Relationship to Child
*
Caregiver 1: Phone Number
*
(###)
###
####
Caregiver 1: Email
Caregiver 1: Preferred form of communication
*
Caregiver 2: Full Name
If applicable
First Name
Last Name
Caregiver 2: Pronouns
If applicable
Caregiver 2: Relationship to Child
If applicable
Caregiver 2: Phone Number
If applicable
(###)
###
####
Caregiver 2: Preferred form of communication
If applicable
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1: Pronouns
*
Emergency Contact 1: Relationship to Child
*
Emergency Contact 1: Phone
*
(###)
###
####
Emergency Contact 1: Email
*
Emergency Contact 2
*
First Name
Last Name
Emergency Contact 2: Pronouns
*
Emergency Contact 2: Relationship to Child
*
Emergency Contact 2: Phone
*
(###)
###
####
Emergency Contact 2: Email
*
Do you grant permission for your girl to be dismissed without a caregiver?*
*
If not, who do you anticipate will pick-up your girl(s)?*
Race and Ethnicity
*
Gender
*
Does your girl have any chronic medical conditions? Check all that apply.
*
Does your girl have any environmental allergies (e.g., pollen, dust)?
*
If yes, please list the specific environmental allergies.
*
Does your girl have any food allergies?
*
If yes, please list the specific allergies
*
Is your girl currently taking any medications?
*
If yes, please include the names, dosage and administration instructions.
*
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.
Girl Name
*
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.
Girl Name
*
