Parent/Guardian's Name *
Parent/Guardian's Name
Address *
Phone *
Best number to reach you.
Child's Name *
Child's Name
If more than one child, please fill out a new form for each.
Date of Birth *
Date of Birth
Is your child of Hispanic or Latino origin?
What grade will your child being entering in Fall 2018?
Please list any known allergies for your child.
This information is used for grant reporting and will not affect the eligibility of your child.
If yes, please describe.
If yes, please describe.
Transportation is not provided for Play Camps.
I understand that by signing up my child to participate in Brookside Community Play's Play Camp program, he/she may sustain bodily injury in the course of the regular play-based activities of the program, and I agree not to hold Brookside Community Play, Brookside Community Development Corporation, or Brookside Community Church liable for any such occurrence of bodily harm to my child. I also understand and agree that my child may be photographed or video recorded with or without my consent and such images and video footage of my child may be used in promotional materials for Brookside Community Play. *