Youth Multi-Media Day Camp - Cook County Higher Education

Youth Multi-Media Day Camp – Camper Details Form

Please fill in all required fields for each child you have registered for. Required fields are marked with a red asterisk.

Camp Details:
Dates: Monday, August 07 through Friday, August 11, 2023
Time: 9:00 AM-5:00 PM CDT
Location: North Point, 19 1st Ave W Grand Marais, MN 55604
Camp Schedule Outline

If you have any questions or difficulties filling out this form or would like to pick up a printed version or sent a PDF please call 218-387-3411, ext 4, or email office@mycche.org

Camper Information

Child's Name *

First

Last

Date of Birth *

Age *

Pronouns

Will they be bringing their own smartphone? *

Parent/Guardian Contact Information

Only one Parent/Guardian is required, but please fill out contact information for both if the child has more than one Parent/Guardian.

Parent/Guardian #1 Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Parent/Guardian #2 Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian #2 Phone

Parent/Guardian #2 Email

Child lives with *

Person responsible for payment *

Alternate Pickup/Release

Please fill this out if someone else other than a Parent/Guardian will be picking the child up.

Alternate #1

Name

Phone

Relationship to Child

Alternate #2

Phone

Relationship to Child

My child is allowed to leave North Point without an adult picking them up. *

Medical Release Information

Does your child have any medical concerns we should be aware of? i.e. Diabetes, Asthma, Seizures, etc. *

Is your child allergic to any foods or medications? *

Medical Insurance Provider *

Medical Insurance Policy Number *

Primary Physician Name: *

Primary Physician Phone *

Hospital Preference *

Emergency Contacts

Please list at least one emergency contact.

Contact #1 Name *

Phone *

Relationship to Child *

Contact #2 Name

Phone

Relationship to Child

Parent/Guardian Authorizations

Please note how you heard about the Youth Multi-Media Day Camp *

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached I authorize calling a doctor and providing necessary medical services in the event my child is injured or becomes ill. *

Parent/Guardian’s Initials

I understand that the Youth Multi-Media Day Camp, Cook County Higher Education, North Point, and Boreal Community Media will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *

Parent/Guardian’s Initials

The Youth Multi-Media Day Camp and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hearby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). *

Printed Name of Parent/Guardian

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