Grow Registration 2018

Girls Rock Our World - G.R.O.W Inc.
Summer Camp
 GROW is 5 weeks - June 25th-July 27th.

 The Session weeks are 5 days Mondays-Fridays, with the exception of the 4th of July.
 Our Program includes: workshops, volunteerism, team building activities, speakers…etc.
 Please Fill Out Registration form below clearly and completely.
 Registration can be completed also Online or at our Open House Registration Dates at the
Facility. Check Website for Dates and Form. Registration fee is DUE when Form is Complete in
order to Lock in Space for your Girl.
 Registration fee is: $40 this includes GROW Girl Camp Tee-Shirts and Journals.
 This Fee is Non-refundable!
 Registration Ends June 18th
 1st Camp Tuition Payment is DUE: June 18th -July 27th for 1st 2-week Session. Bi-weekly or
Monthly Payment Options.
 Every Girl must have an Emergency/Medical form completed.
 G.R.O.W Handbooks will be distributed after Registration and Camp 1st Session Tuition is Paid.
STUDENT INFORMATION
First Name Middle Last Nickname Date of Birth
Address Street Phone
City State Zip Phone
Mother Father
Name Name
Address Address
Home Phone Home Phone
Cell Phone Cell Phone
Work Phone Work Phone
Email Email
Summer Camp
G.R.O.W Emergency Form
STUDENT INFORMATION
Name Middle Last Nickname
Address Street
City State Zip
Date of Birth
Phone #
MOTHER FATHER
Mom Name Dad’s Name
Address Address
Home Phone Home Phone
Cell Phone Cell Phone
Email Email
Occupation Occupation
Employer Employer
Work Phone Work Phone
Student lives with: Both Parents Mother Father Legal Guardian Grandparent
Are there any custody issue? No Yes If yes, please provide camp with custody order.
Summer Camp
HEALTH
Pediatrician Phone
Address
Insurance Co. Policy Number
Name of Insured Member Group Number
Child’s General Health since birth (Describe)

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergic Conditions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Any Recent Illness? _____________________________________________________________________
_____________________________________________________________________________________
Special Problems Needs: ________________________________________________________________
____________________________________________________________________________________
Physical Disability:
______________________________________________________________________
_____________________________________________________________________________________
Vision Problems:_______________________________________________________________________
Speech Difficulties: _____________________________________________________________________
Medication taken by child: _______________________________________________________________
Does your child have any medical needs (allergies, asthma…etc.) that may require emergency care?
YES or NO
If YES, Please answer the following questions…
Name of Medical Condition: ______________________________________________________________
Signs and Symptoms to look for: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Summer Camp
_____________________________________________________________________________________
_____________________________________________________________________________________
If Signs and Symptoms appear, do this:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
To Prevent Incidents:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Other Instructions and Comments:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EMERGENCY MEDICAL CONSENT
I, _________________________________ parent/guardian of _____________________________date

of birth being________________________________ do hereby give permission to the staff of GROW to
secure and authorize such emergency medical care and/or treatment as above-named child might
require while under the supervision of staff at G.R.O.W Summer Camp. I further authorize said staff to
administer emergency care/treatment as required, until medical assistance is available. I also agree to
pay all costs and fees contingent of any emergency medical care and/or treatment for said child as
secured or authorized under this consent.
Parent Signature: ______________________________________________________________________
Date: _____________________________
Please List 3 Individuals that may contacted in case of an Emergency and Parents can Not be reached.
NAME RELATION TO CHILD PHONE NUMBER CHECK IF AUTHORIZED

TO PICK THEM UP
Individuals who are NOT on this list will NOT be permitted to pick up your child without written consent
from a parent. For the safety of your child, picture ID is required!
No student can start without this document. NO EXCEPTION!
Child School: _________________________________________________________________________

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Girls Rock Our World - G.R.O.W Inc.

 GROW is 5 weeks - June 25th-July 27th.

First Name Middle Last Nickname Date of Birth

First Name Middle Last Nickname Date of Birth

Address Street Phone

City State Zip Phone

Home Phone Home Phone

Cell Phone Cell Phone

Work Phone Work Phone

G.R.O.W Emergency Form

City State Zip

Home Phone Home Phone

Cell Phone Cell Phone

Work Phone Work Phone

Insurance Co. Policy Number

Name of Insured Member Group Number

Child’s General Health since birth (Describe)

Any Recent Illness? _____________________________________________________________________

Special Problems Needs: ________________________________________________________________

Speech Difficulties: _____________________________________________________________________

Medication taken by child: _______________________________________________________________

If YES, Please answer the following questions…

Name of Medical Condition: ______________________________________________________________

Signs and Symptoms to look for: __________________________________________________________

If Signs and Symptoms appear, do this:

Other Instructions and Comments:

EMERGENCY MEDICAL CONSENT

I, _________________________________ parent/guardian of _____________________________date

Parent Signature: ______________________________________________________________________

NAME RELATION TO CHILD PHONE NUMBER CHECK IF AUTHORIZED

No student can start without this document. NO EXCEPTION!

Child School: _________________________________________________________________________

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I, _____ parent/guardian of _date