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BODY SOVEREIGNTY CAMP 2023 - REGISTRATION
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*
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Step
1
of
5
20%
If you have any questions or problems filling out this form, please email
[email protected]
or give us a call at (703) 675-2323
Email
*
Camp Session
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Body Sovereignty Camp Nov 20-22 - $444
How many children are you enrolling in camp
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family discount $111
One
Two
Three
Enter Discount Code
Camper's Full Name
*
First
Last
Camper's Date of Birth
*
MM slash DD slash YYYY
Camper's Age First Day of Camp
*
Grade Level Camper is entering Fall 2023
*
3rd Grade
4th Grade
5th Grade
6th Grade
Name of Parent/Guardian
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First
Last
Email Address of Parent/Guardian
*
Mailing Address (Street, City, State, Zip)
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Street Address
City
State
ZIP
Cell phone of Parent/Guardian
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Alternate Contact Info of Parent/Guardian
What is the best way to contact you?
*
Email
Phone
First Emergency Contact
*
Name, Contact number, Relationship to Camper
Second Emergency Contact
*
Name, Contact Number, Relationship to Camper
Does the camper have any allergies, dietary restrictions or special needs the staff should be aware of? If so, please list here
*
Is the camper taking medication to treat a physical condition?
*
* If yes, a physician's note and medication list will need to be provided if medication is required during camp sessions
Yes
No
Does the camper have any behavioral or emotional issues the staff should know about?
*
*We ask this so that we can be sure we are able to best serve our campers and have adequate staff on hand if special attention is needed. In no way will this affect whether or not your camper can attend.
Liability Release
*
I understand that attending camp will involve activities such as, body movement, group exercise, breath work and social activities. I fully accept and assume all such risks and all responsibility for losses, costs and damages that may incur as a result of the camper's participation in camp activities.
I agree
Medical Treatment Authorization
*
In case of emergency, accident, illness, or other incapacity occurring while under the Camp's authority, I give my permission for the camper to be treated by medical professionals and admitted to the hospital if necessary. This authorization applies whether or not the charges are covered by my insurance, and I am responsible for all reasonable medical and emergency expenses.
I agree
I disagree - I do not authorize permission for medical treatment
Media Release
*
I authorize Aflo Health, Inc. staff to take audio, video and photographic recordings of this camper. Aflo Health, Inc. shall own all rights to recordings and photographs, to be used and disposed of at the discretion of the Aflo Health, Inc. Audio, video and photos are primarily used for brochures & flyers, and on our website. Camper names are never used without explicit parent/guardian consent; you will be contacted by a staff member before any names are used.
Yes, I consent to having audio, video and photos taken of this camper and you may use these for promotional materials
No, please do not record or photograph this camper at any time during the program
Second Child Information
Camper's Full Name
*
First
Last
Camper's Date of Birth
*
MM slash DD slash YYYY
Camper's Age First Day of Camp
*
Grade Level Camper is entering Fall 2023
*
3rd Grade
4th Grade
5th Grade
6th Grade
Does the camper have any allergies, dietary restrictions or special needs the staff should be aware of? If so, please list here
*
Is the camper taking medication to treat a physical condition?
*
* If yes, a physician's note and medication list will need to be provided if medication is required during camp sessions
Yes
No
Does the camper have any behavioral or emotional issues the staff should know about?
*
*We ask this so that we can be sure we are able to best serve our campers and have adequate staff on hand if special attention is needed. In no way will this affect whether or not your camper can attend.
Third Child Information
Camper's Full Name
*
First
Last
Camper's Date of Birth
*
MM slash DD slash YYYY
Camper's Age First Day of Camp
*
Grade Level Camper is entering Fall 2023
*
3rd Grade
4th Grade
5th Grade
6th Grade
Does the camper have any allergies, dietary restrictions or special needs the staff should be aware of? If so, please list here
*
Is the camper taking medication to treat a physical condition?
*
* If yes, a physician's note and medication list will need to be provided if medication is required during camp sessions
Yes
No
Does the camper have any behavioral or emotional issues the staff should know about?
*
*We ask this so that we can be sure we are able to best serve our campers and have adequate staff on hand if special attention is needed. In no way will this affect whether or not your camper can attend.
Total
Credit Card
*
Card Details
Cardholder Name
