Registration 2025 Summer Camp Registration Form Participant's First Name Participant's Last Name Age D.O.B Gender: Male Female Non-Binary Prefer not to say Ethnicity Black/African American Hispanic White Asian American Indian/Alaskan Native Other Multi-racial School Name: Height: Weight: Eye Color: Brown Hazel Blue Green Gray Amber Black Emergency Medical Information Asthma Diabetes Fainting Spells Convulsion Emergency Medical Information Contact Lens Heart Trouble High Blood Pressure Other Other Emergency Contact/Authorized Pick-Up: Relationship to child Parent's First Name Parent's Last Name Email Phone Number: Home Address: City: State: Zip: Family Household Size 2 Person 3 Person 4 Person 5 Person Total Family Income $26,500 or less $26,501 to $44,200 $44,201 to $66,300 Above $66,300 Permission for Self-Dismissal / Walking Home Yes, I give permission for my child to walk home / self-dismiss at the end of the camp day. No, my child must be picked up by an authorized adult. I hereby give permission for my child to leave camp on their own at the end of the day without an adult present. I understand that once my child is dismissed from camp, Community Lifestyle and its staff are no longer responsible for their supervision. I give permission for my child to participate in walking trips within the Hoboken, Union City and Jersey City neighborhoods. I understand these walks, do not involve entrance into any facility and the route of any walk involves no safety hazards. Programs sponsored by Community Lifestyle has my permission to transport my child on excursions, planned trips and late transports from the main facility to off-site Community Lifestyle facilities and from off-site facilities to the main facility in Hoboken. I understand that all precautions will be taken to ensure the safety and health of my child. Signing below indicates that you have read the 2025 Community Lifestyle Summer Camp Parent Handbook and understand and accept its terms and that i will receive a copy. Please attach your child's Immunization records Waiver Agreement By accepting and typing my name I hereby authorize Community Lifestyle and give my consent to all above. Digital Signature Submit
