Summer Camp Application

Student’s Last Name ________________________________ MI______ First Name___________________________

Gender M/F _____ DOB _________________ Age______ Middle School _______________________________

Address__________________________________________________ Jacksonville, FL ____________

Parent/Guardian/Foster Care Information

_______________________________________________________ __________________ _________________

Name/Relationship to Student Work Phone Cell Phone

Email__________________________________________________

_______________________________________________________ __________________ _________________

Name/Relationship to Student Work Phone Cell Phone

Email__________________________________________________

Family Arrangement: (circle one)

2 Parents Single Female HOH Single Male HOH Foster Care Relative Military Family

Person(s) authorized to remove child (please circle) Mother YES or NO Father YES or NO

Person to be contacted in case of illness, accident, emergency, and authorized to remove the child from the facility in
the absence of a parent or guardian. If none, please circle NONE.

Name_____________________________________ Relationship___________________________________

Work phone______________________ Cell phone________________________

Name_____________________________________ Relationship___________________________________

Work phone______________________ Cell phone________________________

Camp Registration

Please rank your choice of camp week in order from 1-5 based on your preference with 1 being the week you most want
to attend. Space is limited to 40 students per week on a first-come-first-served basis.

________ June 10-14 Pop!Culture: Planet of the Capes Kent Campus

________ June 17-21 Health Science Career Exploration North Campus

________ June 24-28 Programming BYTES Advanced Technology Ctr/Downtown

________ July 8-12 Flying High: Aviation Cecil Center

________ July 22-26 YUM! The Science of Food Advanced Technology Ctr/Downtown
Florida State College at Jacksonville GEAR UP SUMMER CAMP PARTICIPANT MEDICAL RELEASE

Florida State College at Jacksonville (FSCJ) is committed to providing individual attention to each student who
attends our program. To ensure the good health and safety of your child, please complete and return this form.
Students will not be permitted to begin the program without a signed medical release. Thank you for your
cooperation.
Family Doctor Telephone ( )

Does the student wear glasses and/or contacts?

Please list physical injuries or chronic health problems that we should be aware of, e.g. asthma, epilepsy, knee
injury, etc.:_

Please list any medical restrictions or allergies:

Please list any food allergies or dietary restrictions:

Please list any medications your child is taking or any other information that we should be aware of:

If your child needs assistance to take any medication, please initial below, giving us permission to administer the
medication. Please provide a copy of the physician’s prescription. Also, include any additional instructions for
administering the medication.

Parent/Legal Guardian Initials:

Instructions:

If your child needs to take an aspirin or Tylenol, please initial below, giving us permission to administer the
medication.

Parent/Legal Guardian Initials:

If a medical emergency occurs which involves the need to take your child to a doctor or the hospital emergency
room, and we cannot reach you, we must have your written permission for us to seek medical attention or the
doctor will not see the child. All efforts will be made to contact you or the emergency contact person listed
above.

Do you have a medical insurance covering your child?

If so, what is your insurance company?

Policy Number

Please sign below the following statement:

The information in this release form is correct as far as I know. My child has permission to take part in all FSCJ GEAR-
UP SUMMER CAMP activities. I understand that every attempt will be made to contact me in case of an emergency.
In the event I cannot be reached, I give consent to emergency transportation, x-rays, medical treatment(s), surgery or
dental care for my child. I agree to assume responsibility for all charges incurred.

___________________________ ________________________________ _________________

Parent or Legal Guardian (Print Name) Signature Date
 Florida State College at Jacksonville GEAR-UP SUMMER CAMP PARTICIPANT SIGN-IN and PHOTO
RELEASE

Florida State College at Jacksonville (FSCJ) is dedicated to providing an informative and entertaining
experience for the student during GEAR UP SUMMER CAMP activities. GEAR UP SUMMER CAMP faculty
and staff maintain constant supervision for all activities.

Student’s name

By enrollment in this program, I (parent/legal guardian) grant

FSCJ permission to:

• Take photographs, and/or make video or audio recordings of me/my child, and use them in
individual headshots and group photos related to the promotion of the program.

I agree that neither the GEAR UP SUMMER CAMP Faculty and Staff, FSCJ Foundation Inc., Florida State College
at Jacksonville, nor any of its employees, independent contractors, directors and/or officers will be held liable
for injury which may occur to me/my child while attending the GEAR UP SUMMER CAMP. This includes, but is
not limited to, any activities in which I or he/she may participate and/or meals. Furthermore, I hereby release,
waive, discharge, and covenant not to sue and agree to hold harmless the GEAR UP SUMMER CAMP Faculty
and Staff, FSCJ Foundation Inc., Florida State College at Jacksonville and their respective employees,
independent contractors, directors and/or officers (“Releasees”) from any and all liabilities, claims, demands
or injury that may be sustained by me/my child while participating at the GEAR Up Summer Camp or while on
the premises owned or leased by Releasees or other location used for GEAR UP SUMMER CAMP or while
traveling to or returning from the activity where GEAR UP SUMMER CAMP takes place.

_
Participant, Parent or Legal Guardian (Print Name) Date

_ _
Participant, Parent or Legal Guardian (Signature) Date

Transportation
Students can be dropped off/picked up at the camp location at the designated times.

If you would like more information on other possible transportation options, please list the name of your
closest Duval County public high school on the line below:

______________________________________________________________