Print Application Form - Launching Pad Trampoline Park

Camp Launching Pad Registration Form
Circle Camp Week:
June 15-19
June 22-26
July 13-17
July 20-24
August 3-7
August 10-14
_____________________________________________________________________________________________________
Number of Campers:________
Child #1
Name____________________________________________________ Date of Birth______/_______/_______ T-Shirt Size__________
Allergies______________________________________________________________________________________________________
Special Diet____________________________________________________________________________________________________
Medication____________________________________________________________________________________________________
____________________________________________________________________________________________________
Child #2
Name____________________________________________________ Date of Birth______/_______/_______ T-Shirt Size__________
Allergies______________________________________________________________________________________________________
Special Diet____________________________________________________________________________________________________
Medication____________________________________________________________________________________________________
____________________________________________________________________________________________________
Child #3
Name____________________________________________________ Date of Birth______/_______/_______ T-Shirt Size__________
Allergies______________________________________________________________________________________________________
Special Diet____________________________________________________________________________________________________
Medication____________________________________________________________________________________________________
____________________________________________________________________________________________________
Parent/Guardian - Contact Information
Parent/Guardian #1
Name____________________________________________________ Date of Birth______/_______/_______
Street Address_________________________________________________________________________________________________
Town/City _____________________ State _____ Zip Code ______________ Home Phone _______________________
Work Phone____________________ Cell phone ______________________________ E-mail _________________________________
Parent/Guardian #2
Name____________________________________________________ Date of Birth______/_______/_______
Street Address (if different)________________________________________________________________________________________
Town/City _____________________ State _____ Zip Code ______________ Home Phone _______________________
Work Phone____________________ Cell phone ______________________________ E-mail _________________________________
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Camp Launching Pad Registration Form
Emergency Contact Information
Emergency Contact #1
First Name ___________________ Last Name ___________________ Home Phone ________________ Work Phone ______________
Cell Phone ___________________ Email _____________________________________ Relation to child ______________________
Emergency Contact #2
First Name ___________________ Last Name ___________________ Home Phone _______________ Work Phone _______________
Cell Phone ___________________ Email _____________________________________ Relation to child _____________________
Please list those people in addition to parents/guardians who are permitted to pick up your child:
1: ____________________________________ 2: ________________________________ 3: _________________________________
Medical Release Information
Insurance Information
Policy Number__________________________________ Name of Health Insurance Provider_______________________________
Primary Physician___________________________________________________________________________________________
Address___________________________________________________________________________________________________
Phone_______________________________________ Hospital Preference_____________________________________________
Please explain any additional medical conditions or concerns that you would like to notify us about:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I understand Camp Launching Pad will not be responsible for the medical expenses incurred, but that such expenses will be my
responsibility as parent/guardian.
Initial ___________
Photo Release
I hereby give permission for my child to be photographed during the Camp Launching Pad. I understand the photos will be used to
keep a journal of activities, to share during power point presentations and/or for promotional purposes including flyers, brochures,
newspapers, and on the Internet. I understand that although my child’s photograph may be used for advertising, his or her identity will not
be disclosed. I do not expect compensation and that all photos are the property of the Launching Pad.
Initial ____________
Transportation Release
I hereby give permission for the transportation of my child for official Camp Launching Pad activities by modes of transportation
agreed to by the camp organizers.
Initial ____________
Camp Launching Pad is 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. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my
child to be treated by Certified Emergency Personnel (e.g., EMT, First Responder, and/or Physician).
Parent/Guardian Signature: ______________________________________________________ Date: __________________________
Printed Name of Parent/Guardian: _______________________________________________
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Camp Launching Pad Registration Form
EPIPEN ADMINISTRATION PERMISSION FORM
To be completed by parent or legal guardian and placed in zip lock bag with EpiPens:
My Child is Allergic To:_________________________________________________________________
I hereby authorize the staff of Launching Pad Raleigh Trampoline Park Inc. (“Launching Pad”) to administer an EpiPen to my child if he
or she has known exposure and/or a severe allergic reaction to a specified allergen. I agree to release, indemnify, and hold harmless
Launching Pad and any of its staff from lawsuit, claim, expense, demand, or action against them for administering the EpiPen provided
they administer the EpiPen prescribed specifically for my child. I am aware that the injection will be administered by a trained staff
member who is not a healthcare professional. I understand that the Rescue Squad will always be called when an EpiPen is administered to
my child.
The following EpiPen has been prescribed. Check as appropriate:
___ EpiPen (the premeasured dose is 0.3mg. of Epinephrine)
___ EpiPen Jr. (the premeasured dose is 0.15mg. of Epinephrine)
___ My child has received adequate training on how and when to use an EpiPen and can use it properly in case of an
emergency.
Parent/Guardian Printed Name:__________________________________ Date:____________________
Parent/Guardian Signature:_____________________________________
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Camp Launching Pad Registration Form
PAYMENT INFORMATION
Prices:
Full Day – $350
Half Day – $160
Early Drop-Off (8:00-8:30am) – $5/day
Late Pick-Up (5:30-6:00pm) – $5/day
Sibling Discount – 10% of Full Day or Half Day rate for each child after the First Child pays full price
Payment Calculation:
Full Day
Half Day
Early Drop-off
Late Pick-up
Total per Child
Child #1 $350 = _______
$160 = _______
# Days * $5 = _______
# Days * $5 = _______
__________
Child #2 $315 = _______
$144 = _______
# Days * $5 = _______
# Days * $5 = _______
__________
Child #3 $315 = _______
$144 = _______
# Days * $5 = _______
# Days * $5 = _______
__________
TOTAL PAYMENT
__________
Payment Options:
______ Check Payable to Launching Pad Trampoline Park
______ Credit Card - please provide the following information:
Name on Card________________________________________ Card Number________________________________________
Expiration Date______________ CVV______________ Zip Code ________________
If paying by credit card, you may email completed forms to camp@launchingpadraleigh.com
OR
Mail or bring payment along with completed registration form and waiver to the following address:
Launching Pad Trampoline Park
ATTN: Camp Director
6421 Hilburn Drive
Raleigh, NC 27613
All registration forms and payment must be received 7 days in advance. Changes to your reservation must be made 7 days in
advance. All payments are final.
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