Microsoft Word - !Pep Squad Camp Registration Form …



PLEASE COMPLETE THE ENTIRE FORM NORTH EAST PEP SQUAD SUMMER CAMP 2017 REGISTRATION FORMNAME _______________________________________________HIGH SCHOOL _____________________ LastFirstM.I.ADDRESS ____________________________________________________ HOME PHONE Street AddressZip Code________________FATHER _____________________________________________________WORK PHONE ________________ MOTHER ____________________________________________________WORK PHONE _________________ GUARDIAN __________________________________________________PHONE ________________________ MEDICAL INFORMATION: DOCTOR ______________________________ PHONE _____________________ Hospital Preference _______________________________Date of Last Tetanus Shot ____________________Allergies to Medicine__________________________________________________________________________Special Medical Problems & Method of Treatment_________________________________________________If I cannot be reached in the event of a medical emergency, I authorize North East Pep Squad Summer Camp Personnel to take my daughter to a hospital for emergency medical treatment.HEALTH INSURANCE INFORMATION:Company _______________________________________________________________________________ Name of Policy Holder ____________________________________________________________________ Policy Number ______________________________ Group Number _________________________Parent/Guardian Signature _________________________________________________________________My daughter, ______________________________________________has my permission to attend North East Pep Squad Summer Camp from 7:30am- 3:00 pm each day; Monday, August 7th through Tuesday, August 8th. Ihave read and understand this information regarding the camp. I understand that I am responsible for providing transportation to and from the camp on these dates.Parent/Guardian Signature __________________________________ Date ___________________________Payment of $30.00 & form: MAKE CHECK PAYABLE TO N.E.I.S.D. (North East Independent School District) Return registration form and payment to the Pep Squad Director at YOUR high school.TO BE FILLED OUT BY PEP SQUAD DIRECTORPayment:Check Number: _____________Date______________ Amount: _______________ Method: checkm/ocashSponsor’s signature ___________________________________________________________________________ ................
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