Summer Camp Emergency Contact Form (Ages 5+)

(Five Year Olds must have completed Kindergarten to participate in Summer Day Camp in the school age camp.)

Child's Last Name Child's First Name Age
Home Phone Number - - Birth Date(mm/dd/yyyy) Male/Female
Home Address City Zip/State

  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 State
Phone Number - - Phone Number - -
Additional Phone Number - - Additional Phone Number - -
Employer Employer

Emergency Contact

Last Name Address
First Name City
Phone Number - - Zip
Additional Phone Number - - State

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:

School Information

My child attends the following school:
My child has completed     grade.

Swimming Level

Please choose the level/are your child is allowed to swim. Please note that College Station Parks and Recreation do not allow the use of life jackets within the deep areas of the pools.

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.

Transportation Agreement

I hereby give consent for my child to be transported to and from the field trips.

Field Trip Agreement

I understand that in order for my child to participate in camp, they must arrive no later than 1 hour before the bus is scheduled to depart for the field trip (see Field Trip Schedule). After the field trip deadline has passed I understand that my child may not be dropped off until the bus returns from the field trip.

Refund Policy

I understand that there are no refunds for missed camp days and that missed camp days may not be carried over from one day to the next.

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.

Date: 04/17/2021
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