EmailMe Form - Camp Sunshine Summer Youth Enrichment Program

CAMPER GENERAL INFORMATION

Camper's Name *

First Last

Gender *

Date of Birth *

MM / DD / YYYY

Age *

Camper's Home Address *

Street Address City State / Province / Region Postal / Zip Code

Current Grade Level (2025-2026 Academic Year) *

Please select your student's current grade level. NOT the grade he/she will be promoted to in the fall.

School District *

Current School *

Student ID Number (If Applicable)

T-Shirt Size *

Be sure to select the correct size. Exchanges will NOT be permitted.

Please also note that t-shirts are mandatory for all outings. Failure to wear camps shirts on the designated days will result in the staff asking parents to retrieve the shirt before the bus departs for the outing.

Additional T-Shirts *

Campers will be issued one camp shirt. To order additional shirts, please select the quantity desired below. If ordered, the cost ($13.00) for the additional shirt(s) will be added to your registration invoice.

Primary Language Spoken *

Race/National Orgin *

Does the student have a documented disability? *

Yes

No

If YES, you MUST provide supporting documentation and complete the next three questions. If No, Please proceed to Parent/Guardian Information.

Upload Supporting Documentation

If yes, do you have

an Individualized Education Plan (IEP) from the school system

a Section 504 Plan

a medical diagnosis from a doctor

other

If you answered yes to the above, how would you best classify the type(s)?

Who does the child live with? *

PARENT/GUARDIAN INFORMATION

Parent/Guardian 1 *

First Last

Relationship *

Is the address for Parent/Guardian (1) the same as the camper? *

If NO, please enter the address below:

Street Address City State / Province / Region Postal / Zip Code

Mobile Phone *

### - ### - ####

Work Phone

### - ### - ####

Email *

Parent/Guardian 2

First Last

Relationship

Is the address for Parent/Guardian (2) the same as the camper? *

If NO, please enter the address below:

Street Address City State / Province / Region Postal / Zip Code

Mobile Phone

### - ### - ####

Work Phone

### - ### - ####

Email

EMERGENCY CONTACT INFORMATION

Full Name *

First Last

Relationship to Camper *

Mobile Phone *

### - ### - ####

Work Phone

### - ### - ####

Is the above person authorized to pick-up child? *

Yes

No

Full Name *

First Last

Relationship to Camper *

Mobile Phone *

### - ### - ####

Work Phone

### - ### - ####

Is the above person authorized to pick-up child? *

Yes

No

HEALTH INFORMATION

All health conditions including allergies MUST be disclosed to ensure student safety.

Are there any medical conditions or behavioral problems? *

Yes

No

If yes please explain

Does your child have any allergies (food, nuts, etc.)? *

Yes

No

If yes please list allergies

Are there any activities the child may not participate in? *

Yes

No

If yes please list activities

CONSENTS AND DISCLOSURES

Registration Fees

I understand that there is a one-time registration fee of $52.00 for the 2026 summer session. I understand that this fee is non-refundable and must be paid at the time of registration. *

I understand & agree

Payment Schedule

I understand and agree to the following:

1. Payments for tuition are on due on Friday.

2. If the weekly payment is not received on Friday, drop-off on Monday will not be permitted.

Please note that the payment for week one is due on June 5, 2026. *

I understand & agree

Consent to Medical Treatment & Assumption of Risk and Release.

In the event of injury to or illness of the registrant, the undersigned hereby authorizes Sunshine’s Heart, Inc. or representative thereof, to admit the registrant named to a facility for emergency medical treatment as may be deemed necessary to his/her health welfare. The undersigned hereby consents to whatever medical treatment is deemed necessary and releases Sunshine’s Heart, Inc., their board members, staff, volunteers and agents from and against any and all claims and losses, including, but not limited to attorney’s fees and court costs, arising out of the admission to, or treatment administered. *

Yes

No

Media Release - Parental Consent

Please be advised, that when participating in Camp Sunshine's Summer Youth Enrichment Program, your the registrant may be photographed, videotaped or interviewed at various events. With your consent, the images, video or interview may be used in promotional materials, news releases, social media and other published formats for Sunshine’s Heart, Inc. and its community partners. The images will be the sole property of Sunshine’s Heart, Inc. I understand there is no financial compensation for this agreement and hereby authorize Sunshine’s Heart, Inc. and the members of its staff to take such photographs, recordings and/or live transmission, and likenesses of the registrant. *

Yes

No

I hereby authorize Sunshine's Heart, Inc. to transport the registrant on approved fieldtrips and outings. I understand that Sunshine's Heart, Inc. will use insured transportation companies for transportation. The undersigned hereby acknowledges and agrees that participation in the summer camp program and related activities carry with it an inherent risk of physical injury. In consideration of the registrant’s participation in the program, the undersigned, on behalf of the registrant, hereby assumes all such risks of physical injury and does hereby release and forever discharge Sunshine's Heart, its commissioners, staff, employees and agents from any and all liability, claim or loss arising from bodily injuries or damage to personal property resulting from the registrant’s involvement and participation in the program. *

Yes

No

I hereby authorize the registrant to walk to and from the program site. I understand that he/she must enter the building and immediately go to the program area upon arrival. At dismissal, the registrant must exit and leave the grounds immediately. The program reserves the right to revoke permission to walk in cases of inclement weather or activity along the route that may jeopardize the registrants safety. *

Yes

No

Late Pick-Ups & Penalties

All campers must be picked up by 5:00pm. Parents/Guardians will be given a 10-minute grace period. Any pick-ups after 5:10pm will result in fee of $20.00 (per child). After 5:30pm, an additional $1.00 will be billed per minute. *

I understand & agree

Your signature below indicates that you have read, understand and agree to the above items and that the information on this enrollment form is complete and accurate.

Signature (Parent/Guardian 1) *

Clear

Signature (Parent/Guardian 2)

Clear