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Carlisle Response Network – CRN
Programs
Little Wonders Preschool
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Empowerment
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Board Portal
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Home
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Summer 2023 Youth Camps
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Summer 2023 Youth PRIDE Camp
Summer 2023 Youth PRIDE Camp
Pride Camp Registration 2023
Capped at 20
Participant Name
(Required)
First
Middle
Last
Gender
Age
(Required)
Grade
(Required)
School
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Caregiver/Guardian Name
(Required)
First
Middle
Last
Caregiver Email
Home Phone
(Required)
Cell Phone
Work Phone
Pick-up
(Required)
I understand that I am responsible for picking up my child up at 3:00pm from YWCA Carlisle and Cumberland County.
Emergency Contact Information
If you cannot be reached, please provide two names of local persons to contact in case of emergency.
Name
(Required)
First
Last
Relationship to Participant
(Required)
Phone
(Required)
Name
(Required)
First
Last
Relationship to Participant
(Required)
Phone
(Required)
Allergies/Other Medical Conditions
Media Release
Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to YWCA Carlisle and Cumberland County, their affiliates and agents, to use my image and likeness and/or any testimonial statements from me in its publications, advertising, social media, or other media activities. This consent includes, but is not limited to:
(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice
(b) Permission to use my name; and
(c) Permission to use quotes from the testimonial(s) (or excerpts of such quotes), the film, photograph(s), tapes (s) or reproduction (s) of me and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio educational and awareness.
I recognize that if the box is not checked, my child may be omitted from group photos, and will not be
I agree to the media release
Release of Liability
I understand that, in the event of an emergency involving my child, it may be necessary for a staff person or other representative of YWCA Carlisle & Cumberland County to administer basic first aid to my child and/or transport my child to a hospital, physician's office or other health care facility. I hereby consent to the treatment and/or transportation of my child under such circumstances, and release YWCA Carlisle & Cumberland County, its employees, President/CEO and agents from any claim arising out of or related to such treatment or transportation, except in the case of gross negligence. I will bear all expenses incurred in transportation and medical treatment.
I agree to the release of liability
Pride Summer Camp - One Week
Quantity
(Required)
Price:
$150.00
Quantity
Registration is non-refundable, and includes full week of camp from June 19-23, 9am-3pm.
Total
Credit Card
Cardholder Name
Card Details
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