Gurmat Summer Camp Registration (copy) – CT Gurdwara Nanak Darbar

Gurmat Summer Camp Registration

First Name

Last Name

Date of Birth

Age

Gender

Male

Female

T-shirt Size

Youth

Adult

Parents Detail
Full Name

Mother

Father

Address

Street:

Apartment:

City:

Country

Zip:

Phone Number

Cell Phone Number (Mother)

Cell Phone Number (Father)

Emergency Contact (SOMEONE OTHER THAN PARENTS)

Full Name

Phone

Medical Insurance

Company

Policy Holder

Policy No.

If an emergency were to occur, can a camp volunteer administer over the counter medication to your child:

Yes

Volunteers are allowed to administer any medication or anything relating to your child's health listed below:
Please sign below to confirm your child's attendance and return completed form (Both pages) with $50 registration fee (Check Payable To: CSA) or: Karamjit Kaur Chawla (Tel: 203-768-9179)

Does Your Child Have Any Allergies to Food:

Yes

Please List Below

Does Your Child Have Any Allergies to Medication:

Yes

Please List Below

Does Your Child Have Non-Food Allergies (Pollen, Bees, Dust etc.)

Yes

Please List Below

Does Your Child Have Daily Medication(Inhar, Allergy, MEdication Etc.):

Yes

Please List Below

Does Your Child Require any Special Medical attention

Yes

Please List Below

Does Your Child need an Epi-pen?

Yes

Please Leave one with

Is a Volunteer permitted to assist in administering your child with the Epi-pen

Yes

Please authorize by signing:

Does your child need an inhaler?

Yes

Are one of the designated camp volunteers allowed to administer?

Yes

Please authorize by signing:

Is your child vaccinated against COVID-19?

Yes

If there were to be a serious incident/emergency the parents will be contacted first and then the emergency contact. If unreachable emergency services will be contacted.

Please authorize by signing:

Date / Time

Photo and Video consent

Do you give permissions for your child to be photographed and/or videotaped during camp activities?

Yes

Please autorize by signing:

Camp Registration Fee

Price: $50.00

Pay with Card (Stripe)

Stripe test mode activated

Contact Us

Gurdwara Vedios

Login To Admin