Holiday Camp Emergency Contact Form (Ages 5+)
Child's Last Name
Child's First Name
Age
Home Phone Number
-
-
Birth Date(mm/dd/yyyy)
Male/Female
Male
Female
Home Address
City
Zip/State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
  N/A
  N/A
Father's Last Name
Mother's Last Name
Father's First Name
Mother's First Name
Address(if different from child's address)
Address(if different from child's address)
City
City
Zip
Zip
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Phone Number
-
-
Phone Number
-
-
Additional Phone Number
-
-
Additional Phone Number
-
-
Employer
Employer
Emergency Contact
(MUST BE SOMEONE OTHER THAN MOM AND DAD AND LIVE AT A DIFFERENT ADDRESS THAN THE CHILD)
Last Name
Address
First Name
City
Phone Number
-
-
Zip
Additional Phone Number
-
-
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Relationship
Additional Persons Authorized to Pick Up the Child
In addition to my child's legal guardians and emergency contact listed above, I hereby authorize Powersports to allow my child to leave
ONLY
with the following persons. Name and telephone number are needed for each. Children will only be released to a parent or person designated by the parent/guardian after verification of ID.
Last Name
First Name
Phone Number
-
-
Optional: I hereby give my consent for my child to be released to the following siblings who are under 18 years.
Name of Sibling(s)
Medical Information
List any medical problems that your child may have, such as allergies, exiting illnesses, previous serious illness, injuries, any medication prescribed for long-term continuous use, and any other information which caregivers should be aware of:
Child daycare operations are public accommodations under the Americans with Disabilities Act (ADA), Title III. If you believe that such an operation may be practicing discrimination in violation of Title III, you may call the ADA Information Line at 800-514-0301 (voice) or 800-514-0383 (TTY).
Agreements are found in the After School/Summer Camp Handbook
Authorization for Emergency Medical Attention Agreement
In the event that I cannot make arrangements for emergency medical care, I authorize the person in charge to take my child to:
St. Joseph Regional Health Center, 2801 Franciscan Dr, Bryan, TX 77802, 979-776-3777
College Station Medical Center, 1604 Rock Prairie Rd, College Station, TX 77845, 979-764-5100
The Physicians Hospital, 3131 University Dr East, Bryan, TX 77802, 979-731-3100
Scott & White Healthcare, 1600 University Drive E, College Station, TX 77840, 979-691-3300
Scott & White Memorial Hospital, 700 Scott & White Dr, College Station, TX 77845, 979-691-3400
School Information
My child attends the following school:
Bonham Elementary
Bowen Elementary
College Hills Elementary
Creekview Elementary
Cypress Grove Intermediate
Forest Ridge Elementary
Greens Prairie Elementary
Jane Long Intermediate
Mary Branch Elementary
Johnson Elementary
Mitchell Elementary
Oakwood Intermediate
Pebble Creek Elementary
Pecan Trail Intermediate
Rock Prairie Elementary
Sam Houston Elementary
Sam Rayburn Intermediate
South Knoll Elementary
Southwood Valley Elementary
Spring Creek Elementary
Sul Ross Elementary
ILT Charter School
Other School
My child for the school year 2024-2025 will be in grade
K
1
2
3
4
5
Immunization Agreement
I verify that my child's immunization records are on file at the school and all required immunizations and/or tuberculosis test are current. Vision and Hearing screening records are also on file.
Discipline Agreement
I have read and understand the Student Discipline Guidelines and agree to follow them in accordance to the parent handbook.
Acknowledgment of Handbook
By signing my name, I agree that I have read in full the Powersports After School and Summer Camp policies and procedures and will abide by them.
Also, my signature verifies receipt of the Discipline and Guidance Policies and permits Powersports to obtain emergency medical treatment if needed.
Signature:
Clear
Date:
12/13/2024
By signing here I verify all information in this form is correct and agree to all Powersports policies and procedures.
Once your form is submitted, you must call Powersports to complete your registration