CAMP NICK REGISTRATION

CAMP NICK REGISTRATION
Camper Information

All information provided on this form is confidential
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age (as of 6/5/2023)*
Gender*
Ethnicity*
School*
2023-2024 Grade Level*

3rd4th5th
Primary Address*
City*
State*
Zip*
Camp t-shirt size*
Has the camper ever or is currently receiving counseling or any other psychological or psychiatric services?*

NoYes
If Yes, please explain
What skills are you hoping your camper will work on at Camp Nick?*
Medical/Insurance Information
Known Allergies/food sensitivities
Medications currently taking
Name of Primary Physician*
Physician Phone*
Health Insurance Provider (if none, leave blank)
Policy Holder Name
Member/Group Number
Pre-Authorization Phone
Medical Treatment

In the event I cannot be reached to make arrangements for emergency medical attention, I authorize St. Luke's staff members or authorized counselors to obtain emergency medical treatment in case of illness or injury to the participant named above.
I authorize the staff person in charge to have my child transported to TX Children's or other hospital of choice:*

Texas Children's HospitalOther
Photo Release

I grant permission for Nick Finnegan Counseling Center, it's staff and authorized volunteers, to take photographs and/or video of my child while participating in programs and/or events, and to publish the same (name withheld) in print, electronic and/or broadcast media, for promotional and informational purposes.
I agree or do not agree to the photo release*
Are there any custody agreements related to this minor?
If yes, please provide our office with a copy of custody documents at least 2 days before camp begins.

Parent/Guardian Information

Also referred to as Client Representative for minors
Parent/Guardian First & Last Name*
Date of Birth*

MonthDayYear
Date
Primary Address*
City*
State*
Zip*
Mobile Phone Number*
Is it okay to leave messages at this number?*

YesNo
Home or Work Phone Number*
Is it okay to leave messages at this number?*

YesNo
What's your best email address?*
example@example.com
I allow NFCC to contact me via email regarding camp updates and billing*
I understand that there are risks associated with email communication and confidentiality
Emergency Contact Information

NFCC will contact this person if there is an emergency situation during camp and we are not able to reach the parent/guardian listed above.
Emergency Contact First & Last Name*
EC Phone*
Relationship to client

Acknowledgement of Receipt – Notice of Privacy Practices & Informed Consent for Treatment*
Authorization for Treatment

I agree that I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me.
Parent/Guardian Signature*

Clear
Should be Empty:

CAMP NICK REGISTRATION

Camper Information

Medical/Insurance Information

Parent/Guardian Information

Authorization for Treatment