Parent/Legal Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Student Name *

Student Goes By

First Name

Last Name

Student's Birthday *

MM

DD

YYYY

Emergency Contact Information *

In case of emergency, please list the name(s) and phone number(s) of whom you would like us to contact other than the parent or guardian:

First Name

Last Name

Phone *

(###)

###

####

First Name

Last Name

Phone

(###)

###

####

Pick Up Information *

The following people may pick up my child when camp is finished each day: Drivers license/form of ID will be required at pick-up.

First Name

Last Name

First Name

Last Name

First Name

Last Name

Request for Self-Administration of Medicine *

If your child does not require medication during program hours select "NO." This form states that your child understands the need for this medication and the necessity to report to the designated “Heidi Elnora Fashion Camp” counselor any unusual side effects. He/she is capable of using this medication independently under the supervision of the designated “Camp Fashionista” counselor. By selecting "YES", the parent/guardian acknowledges that they have read and understand the ”Heidi Elnora Fashion Camp” policy regarding the self-administration of medication. Furthermore, the "YES" holds Heidi Elnora Birmingham, LLC, Heidi Elnora Atelier, and “Heidi Elnora Fashion Camp” harmless for any and all outcomes resulting from said self-administration of medication.

Yes

No