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H.Y.P.E. LEADERSHIP CAMP REGISTRATION FORM

School Attending 2013-14:______________________
DOB:________________ Age:____ Grade 2013/14:____
Child's Name:_________________________________________ T-Shirt Size: S M L XL 2XL 3XL 4XL (circle one)Boy/Men
Parent's Name(s):______________________________________ Home Phone:____________________________________
Email:_______________________________________________ Work:___________________ Cell:___________________
Mailing Address:

Street/P.O. Box City Zip Code

HYPE LEADERSHIP CAMP PROGRAM July 8-11 2014 (5pm-8pm) & Saturday 9:30-4
THE FOLLOWING PEOPLE HAVE MY PERMISSION TO PICK UP MY CHILD IF I AM UNABLE TO DO SO:
Name:_________________________ Relationship:______________________ Phone:________________________
Name:_________________________ Relationship:______________________ Phone:________________________
Name:_________________________ Relationship:______________________ Phone:________________________
Name:_________________________ Relationship:______________________ Phone:________________________
I understand that I must send a note in advance when someone other than those listed above will be picking up my child(ren).
Only original applications accepted. Enrollment is first-come, first -served. Fee is $100/person Checks/Money Oders payable to HYPE. For
more information, call Willie Joyner, Director 252-258-0123 or Andrea Green, Program Coordinator 252-702-4620.
EMERGENCY INFORMATION - MUST COMPLETE
Mother: Place of Work: Phone:
Father: Place of Work: Phone:

Other Emergency Contact: Phone:
Can be someone from the pick-up list

Doctor:_________________________ Phone:________________
Dentist:________________________ Phone:________________
Preferred Hospital Vidant Medical Center (Please change if other than Vidant)
List medications being taken regularly:
List any allergies your child has:
(If this information changes please update form with your teacher)
Insurance Policy Carrier_______________________________________ Insurance Policy Number_________________________________
Is there information we should know regarding your child's participation? __ Yes __ No If yes, please explain on next page

PHOTO CONSENT
PHOTO CONSENT


Occasionally, we may take photographs of the children in our program. We may use these images in printed publications or on our website. We will not
release any personal details or names in our publications or website. I hereby
____ GIVE ____ DO NOT GIVE my consent for my child/children to be photographed for the reasons stated above.

Parents Signature_________________________ Printed____________________ Date______



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Medical History
Does Your Child:
1. Have any Dietary Restrictions? Yes or No
2. Take Any Medications? Yes or No
3. Have any hearing problems? Yes or No
4. Have any vision problems? Yes or No
5. Have any speech problems? Yes or No
6. Have any behavior issues? Yes or No
7. Have any restriction issues? Yes or No
8. Have any past health issues? Yes or No
9. Have any food allergies? Yes or No
10. Have other allergies? Yes or No
11. Have asthma? Yes or No
12. Have any special needs? Yes or No

Please explain any yes answers from above for each child that will be participating:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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MEDICAL CONSENT FORM

I, ______________________________________________ (parent), agree that the Director may authorize a
physician to provide emergency care if the parent/guardian is unavailable.

By signing below, I agree to allow HYPE to transport and to seek emergency care as listed above from a
hospital or physician in the event my child is medically ill or injured.

______________________________________________________________________________
HYPE Members Signature Date

______________________________________________________________________________
Parent/Guardians Signature Date

______________________________________________________________________________
HYPE Representatives Signature Title-Director or Program Coordinator Date

HYPE Leadership Camp AGREEMENT, WAIVER & RELEASE FORM

On behalf of myself, my spouse, and each Child designated (my Child) I enter into this Registration Form Agreement
(Agreement) with HYPE Inc./HYPE Leadership Camp, (a service organization), regarding the provision by HYPE
LEADERSHIP CAMP of a supervised, step team environment for my Child(ren).


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I. Facility Use: Subject to this agreement and other terms as a Step Team Leadership Camp the use of facilities may be
any Pitt County School or Dance Studio within the community for the use of practice by which I will not hold anyone
liable that may direct or work with my child as this is a voluntary event that I chose for my child to participate in.
Activities at the facility may include learning and participating in stunts, tumbling, stepping, dancing, and theatrical arts.
HYPE Leadership Camp may/may not provide transportation or take field trips.

II. Future Visits: This agreement, the registration form and the Child Information form will be kept confidential and on
file at HYPE Leadership Camp and will constitute binding obligations for any future visits my Child may make to HYPE
or its Leadership Camp. However, this agreement does not obligate HYPE Leadership Camp to continue to provide
services, and HYPE LEADERSHIP CAMP reserves the right to refuse admission to any child for any reason without
liability. Participation in the camp does not automatically qualify a person for membership.

III. Payment: Payment for HYPE Leadership Camp services will be due on or before July 6. This payment can be made
by money order to be made payable to HYPE for the amount of $100. Participants may also send payment to our Paypal
account hypecrew1995@gmail.com at www.paypal.com. Please put you and your childs name in the message box. HYPE
may also reserve the right to assess late fees for late pickup of your child at a rate of $1/minute.

IV. Health Policies: I agree that my Child is in excellent health and physical condition and has no medical,
psychological, physical, or mental condition, which has not been disclosed to HYPE Leadership Camp on the attached
Registration Form. My Child does not have any infectious, contagious, or communicable diseases. Illness: In the event
that my child should become ill with a contagious illness, I agree to contact HYPE Leadership Camp as soon as possible
to enable HYPE Leadership Camp, in its discretion to notify each family of all the children who may have been exposed.

V. Medical Procedures: 1. General Medical Guidelines/Discretion: Although HYPE LEADERSHIP CAMP tries to
provide a safe environment; it is possible that my Child could get injured. In this event, I authorize HYPE Leadership
Camp to follow its internal procedures, including simple first aid as reasonably appropriate. However, I understand that
HYPE Leadership Camp shall not be required to strictly follow those guidelines when, in HYPE Leadership Camp's
judgment, circumstances require otherwise. 2. Medical Authorization: In the event that HYPE Leadership Camp
determines that emergency medical attention is necessary for my Child, I authorize HYPE LEADERSHIP CAMP to act as
an agent for me and give permission for my Child to be attended by a physician in such circumstances as HYPE
Leadership Camp deems necessary.

VI. Safety/Indemnity: I agree that HYPE Leadership Camp may take action when it considers prudent to protect the
safety of my Child, and other children visiting HYPE LEADERSHIP CAMP. I further agree to indemnify, defend, and
hold harmless HYPE LEADERSHIP CAMP, (and partners, directors, assistants, agents, and employees) from and against
all actions, claims, or liability, including attorney fees and court costs directly or indirectly caused by my Child or
resulting from any inaccuracy or omission made by me in completing the Registration Form.

VII. Additional Requirements: As a condition to my use of HYPE Leadership Camp, I have accurately completed and
signed the Registration Form and Releases. I understand that HYPE Leadership Camp, will rely on this information in
caring for my Child.


VIII. Waiver and Release: In consideration of being allowed to participate in the HYPE Leadership Camp, the
undersigned, on his or her behalf, and on the behalf of the participant(s) identified below, acknowledges, appreciates and
agrees to the following conditions:

I represent that I am the parent or legal guardian of the participant or am the participant listed below, or have obtained
permission from the parent/legal guardian of the participant(s) named below to execute this agreement on their
behalf._________/___________(initials)

I and the participant(s) named below willingly agree to comply with the states and customary terms, rules and conditions
for participation. In addition, if I observe any hazard during the participant(s) participation, I will bring it to the attention

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of the nearest HYPE Leadership Camp Staff immediately; and I understand that the risk of injury can be significant,
including the potential for paralysis and even death, and while particular rules, equipment and personal discipline reduce
the risk, the risk does exist; and I am aware that there are inherent risks associated with participation in HYPE Leadership
Camp programs, parties, and/or use of the play area and play structures and I on behalf of myself and the participant(s)
named below, knowingly and freely assume all such risk. Both known and unknown, including those that may arise out of
negligence of other participants.__________/______________ (initials)

I, myself and on behalf of my heirs, hereby hold harmless HYPE Leadership Camp their officers, agents, employees, other
participants and sponsoring agencies with respect to any and all injury, disability, death, or loss or damage to person or
property to the fullest extent of the law; and the undersigned acknowledges that this release and waiver of liability form
will be used and relied upon HYPE Leadership Camp and that it will govern the undersigneds actions and rights.
____________________/__________________(initials)



I HAVE READ THE ABOVE CAREFULLY AND HAVE FULLY UNDERSTOOD THE CONTENT
AND CONSEQUENCES OF THIS AGREEMENT BEFORE SIGNING.

By signing below for myself, my child/children, participant and/or spouse, I also agree to the above conditions, should I decide to
participate:

Participant Name: __________________________________________________ Date of Birth: _____________________________

Participant Name: __________________________________________________ Date of Birth: ______________________________


Parent 1/Guardian Signature:
___________________________________________________________/Date_________________________________

Parent 1/Guardian Printed:________________________________________________________________(full name)




Parent 2/Guardian Signature:
___________________________________________________________/Date_________________________________

Parent 2/Guardian Printed:________________________________________________________________(full name)




Signature of HYPE LEADERSHIP CAMP Authorized Representative Date