International Summer Camp Registration Form (3rd-6th graders) Please complete the form below to register for Camp Rock International Camp . Step 1 of 2 50% Step 1: Parent/Guardian InformationName* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell PhoneEmail* Enter Email Confirm Email Step 2: Student InformationNumber of Students to Register*Select One12345Student Name* First Last Date of Birth* MM slash DD slash YYYY Gender*Select OneMaleFemaleGrade (2023 - 2024 school yr)*Select OneSecondThirdFourthFifthSixthT-Shirt Size*Select OneYouth Extra SmallYouth SmallYouth MediumYouth LargeExtra SmallSmallMediumLargeExtra Large2XLPlease explain any sleep or sleep walking issues?*Please explain any behavior or discipline issues?*Please explain any medication or allergies?*Can this Student Swim?* Yes No Image Release*Select OneYesNoIMAGE RELEASE: I understand there will be photographs and video taken during the week. I hereby grant Camp Rock permission to use my child(ren)'s image in promotional material.Student 2 Name* First Last Student 2 Date of Birth* MM slash DD slash YYYY Student 2 Gender*Select OneMaleFemaleStudent 2 Grade (2023-2024 school yr)*Select OneSecondThirdFourthFifthSixthStudent 2 T-Shirt Size*Select OneYouth Extra SmallYouth SmallYouth MediumYouth LargeExtra SmallSmallMediumLargeExtra Large2XLPlease explain any sleep or sleep walking issues?*Please explain any behavior or discipline issues?*Please explain any medication or allergies?*Can this Student Swim?* Yes No Student 2 Image Release*Select OneYesNoIMAGE RELEASE: I understand there will be photographs and video taken during the week. I hereby grant Camp Rock permission to use my child(ren)'s image in promotional material.Student 3 Name First Last Student 3 Date of Birth* MM slash DD slash YYYY Student 3 Gender*Select OneMaleFemaleStudent 3 Grade (2023-2024 school yr)*Select OneSecondThirdFourthFifthSixthStudent 3 T-Shirt Size*Select OneYouth Extra SmallYouth SmallYouth MediumYouth LargeExtra SmallSmallMediumLargeExtra Large2XLPlease explain any sleep or sleep walking issues?*Please explain any behavior or discipline issues?*Please explain any medication or allergies?*Can this Student Swim?* Yes No Student 3 Image Release*Select OneYesNoIMAGE RELEASE: I understand there will be photographs and video taken during the week. I hereby grant Camp Rock permission to use my child(ren)'s image in promotional material.Student 4 Name* First Last Student 4 Date of Birth* MM slash DD slash YYYY Student 4 Gender*Select OneMaleFemaleStudent 4 Grade (2023-2024 school yr)*Select OneSecondThirdFourthFifthSixthStudent 4 T-Shirt Size*Select OneYouth Extra SmallYouth SmallYouth MediumYouth LargeExtra SmallSmallMediumLargeExtra Large2XLPlease explain any sleep or sleep walking issues?*Please explain any behavior or discipline issues?*Please explain any medication or allergies?*Can this Student Swim?* Yes No Student 4 Image Release*Select OneYesNoIMAGE RELEASE: I understand there will be photographs and video taken during the week. I hereby grant Lamplight Artists permission to use my child(ren)'s image in promotional material.Student 5 Name* First Last Student 5 Date of Birth* MM slash DD slash YYYY Student 5 Gender*Select OneMaleFemaleStudent 5 Grade (2023- 2024 school yr)*Select OneSecondThirdFourthFifthSixthStudent 5 T-Shirt Size*Select OneYouth Extra SmallYouth SmallYouth MediumYouth LargeExtra SmallSmallMediumLargeExtra Large2XLPlease explain any sleep or sleep walking issues?*Please explain any behavior or discipline issues?*Please explain any medication or allergies?*Can this Student Swim?* Yes No Student 5 Image Release*Select OneYesNoIMAGE RELEASE: I understand there will be photographs and video taken during the week. I hereby grant Camp Rock permission to use my child(ren)'s image in promotional material. Who is dropping off/picking up each camper? Please list the legal name of all approved adults.*For the safety of our campers, it is imperative that we have a complete list of NO MORE THAN 3 individuals who are allowed to drop off and pick up each registered camper. PHOTO ID IS REQUIRED OF ANY INDIVIDUAL PICKING UP CAMPERS.Emergency Contact Name* Emergency Contact Relationship to Camper(s)* Emergency Contact Phone*Emergency Contact Name* Emergency Contact Relationship to Camper(s)* Emergency Contact Phone*Emergency Contact Name* Emergency Contact Relationship to Camper(s)* Emergency Contact Phone*Copy of Insurance Card Drop files here or Select files Max. file size: 512 MB. Please include a scanned copy of your campers' insurance card for our files.I, on behalf of my child(en), give consent for my child(ren) to participate in programming at Camp Rock of Georgia. This waiver is signed as an acknowledgement that Camp Rock staff, volunteers, or affiliates are not liable in the unlikely event of an accidental injury. I hereby release and hold harmless Camp Rock of Georgia, their volunteers, and employees from liability for bodily personal injury, arising as a result of medical and/or dental treatment given to participants and guests prior to their participation in Camp Rock of GA activities. I give consent for the staff and volunteers of Camp Rock of Georgia to act on my child’s behalf should I be unable to do so. I give consent to the camp to provide or assist in the provision of reasonable medical/dental care and treatment deemed necessary for my child’s well-being for the duration of their stay at camp. Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), Camp Rock of Georgia is taking extra precautions with the care of every camper and volunteer to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance. Before arriving at camp, I will ensure that my camper has not had or been in contact with an individual who has had a fever, dry cough, difficulty breathing, or fatigue and consent to a health history review upon arrival at Camp Rock of Georgia events. I acknowledge that Camp Rock of Georgia reserves the right to dismiss (without refund) any persons(s) who does not abide by its policies. If a dispute over this agreement or any claim for damages arises, I agree to resolve the matter through a mutually acceptable arbitration process.Help us can SPAM Δ
