Jane Adams Peacecamp Signup Form

Fields with * are required. This form is SSL secured.

Child's Name *

First Name Last Name

Birth Date *

Month Day Year

Age at Camp *

Entering Grade # *

Parent's Name *

First Name Last Name

2nd Parent's Name

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

- Area Code Phone Number

Work or Cell Phone

- Area Code Phone Number

E-mail

Emergency Contact Name *

First Name Last Name

Emergency Contact Phone *

- Area Code Phone Number

Child's Doctor's Name *

First Name Last Name

Child's Doctor's Phone *

- Area Code Phone Number

Medical Conditions

Allergies

Food Issues

Medicines

Any disability or behavior issues we should know about?

Need Transportation?

FINANCIAL AID: Financial aid is available to families in need. Please share a brief description of your family's economic situation. Include how much of the $200 fee you feel you can afford. The registrar will contact you asap to discuss your request. If you have already discussed this with the registrar, there is no need to repeat the request.

Financial Aid Info

Other Comments or Concerns

PHOTO RELEASE: If I selected Yes for photo release, I allow Jane Addams Peace Camp to use photographs or videos of my child in promotional materials.

I agree to the Photo Release as shown above. *

Yes No

CANCELLATION POLICY: Jane Addams Peace Camp will return tuition fees minus $10.00 processing fee up until Sunday, July 23rd, 2017. After that date fees are only refundable if we can find another camper to take your child's place.

I agree to the Cancellation Policy as shown above. *

Yes No

MEDICAL RELEASE POLICY: CONSENT TO TREAT A MINOR
I/We, being the parent(s) or legal guardian(s) of the above named child, do herby appoint the staff of Jane Addams Peace Camp to act in my/our behalf in authorizing any X-ray, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the above named minor during my/our absence. This document may be relied on by any licensed physician, surgeon, dentist or appropriate hospital representative in accordance with section 25.8 of the Civil Code of California. I/We authorize any hospital which has treated the above minor to surrender physical custody of the minor to my/our/above named agent. This authorization conforms to Section 1283 of the Health and Safety Code of California.

I agree to the Medical Release as shown above. *

Yes No

Jane Adams Peace Camp Registration