DMA Summer Camp Packet - Baton Rouge Community College

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BRCC YOUTH CAMP Summer 2010 Registration Form Student: _______________________________________________ SSN ___________________________ Last First M (REQUIRED) Date of Birth: _____________________ Age: ____ Male ___ Female ___ Entering Grade ___________ Parent/Guardian: ________________________________ Phone Number: ____________________________ Address ________________________________________________________ City ____________________________________ State ______________ Apt. # __________ Zip ________________ HOW DID YOU HEAR ABOUT US? [ ] Friend [ ] Brochure [ ] Ad Are you a returning student to BRCC Youth Camp: [ ] Yes [ ] No WCCE # CRN # TITLE OF COURSE DATES FEES 1001 21543 Entertainment Technology Camp 6/1– 6/26 $650 5/27 - 6/ 25 TOTAL FEE: $650 FEES INCLUDE A $100 SUPPLY FEE PAYMENT INFORMATION Payment must accompany all registrations (Please Do Not Send Cash) Payment Type: [ ] VISA [ ] MC [ ] AMEX [ ] DISCOVER [ ] Check Check # ___________ Expiration Date on Card: __________________________ Signature on Card: ______________________________________________ Make Checks Payable to: Baton Rouge Community College Date: ________________ REGISTRATION INFORMATION Fax Registration with Credit Card Number to: (225) 216-8446 Or call (225) 216-8439 or (225)216-8450
BATON ROUGE COMMUNITY COLLEGE Continuing Education Youth Medical Form It is a necessity to receive the completed form before your child's program begins. To Parents: In order for your son/daughter to receive medical care in the event of illness or injury while participating in a BRCC program, please give the following information: Consent for minors attending special programs through BRCC to receive required medical treatment. Student's Name___________________________________Date of Birth___________________________ SS Number ___________________________ (Required) EMERGENCY CONTACT INFORMATION: Name: ________________________________________ Relationship: _________________________ Phone: Wk: _____________________ Hm: _____________________ Cell ___________________ Fax: ____________________ E-MAIL Address : ___________________________________________ Insurance Company & Policy Number_____________________ Name of person carrying Insurance______________________________ Place of Employment _______________________________ Family Physician: Name________________________________Phone Number: ______________________ Address ______________________________City _____________________State _________Zip__________ List any medical condition(s) that you would like BRCC/Continuing Education to know in order to attend to your child: List all known allergies, medications or foods to which your child is allergic: List any special accommodations that your child my require to participate in this program: BRCC STAFF WILL NOT ADMINISTER ANY MEDICATIONS TO YOUR CHILD/CHILDREN Medical Treatment Consent and Liability Release: I, parent/guardian, grant to BRCC/ Continuing Education or any of its representatives, full authority to take action deemed necessary to protect the health and safety of my child at my expense, to include but not limited to placing said child under the care of a doctor, EMS personnel, or in a hospital for medical treatment if necessary. I have read the foregoing and understand its terms, and I fully agree to all the provisions set forth therein. Parent/guardian name (print) _____________________________________ Parent/Guardian Signature __________________________________
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DMA Summer Camp Packet - Baton Rouge Community College

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