Please be advised that the camper must be picked up by a parent, guardian, or other authorized adult 18 years of age or older. If someone other than the listed parent/guardian is going to pick up the camper please list them here and dictate their relationship to the camper. For example; Grandma, babysitter, uncle etc. 

If an epi-pen is needed please dictate that below. 

Please be advised, Campers are to remain in the building during camp hours. In the event of an emergency, emergency contacts listed will be notified. As well as the name of the emergency contact, please add the best contact number for them as well. 

Please note this information is only in case of emergency. If this information is needed the Camper’s appointed emergency contacts will be notified. 

Please note this information will not be shared, it is only used to determine scholarship eligibility. 

Please note this information will not be shared, it is only used to determine scholarship eligibility. 

I, the undersigned, certify that the information provided above is accurate to the best of my knowledge. I hereby give consent for my child to participate in all activities associated with the Unite & Write Writing and Publishing Camp. I authorize camp staff to seek appropriate medical care in the event of an emergency.

By signing this form, I release and hold harmless Unite & Write Writing and Publishing Camp and Local Lore Music Company from any liability for injuries, illnesses, or other incidents that may occur during camp activities.