CHAMP Camp Registration 2024

If you are registering more than one camper, please complete the following information on the first camper, then click "Register & Add Attendee" to enter the information on another camper. Payment includes camp equipment, surprise activities, a daily snack, and a T-shirt. For additional information or if you have any questions, please contact Dr. Kristen Morgan at (985)549-3869 or kristen.morgan@selu.edu.

Vendor: CHAMP Camp

Location: Kinesiology and Health Studies Gymnasium, 400 Mane Street , Hammond, LA 70402

Date/Time: Monday, June 10, 2024 - Thursday, June 13, 2024 9:00 AM - 12:00 PM

Add To Calendar

Fields with asterisk are required.

Camper First Name *

Camper Last Name *

Camper Country *

Camper Address 1 *

Camper Address 2

Camper City *

Camper State *

Camper Zip Code *

Camper Phone Number *

Camper Email *

Parent/Primary Contact Name *

Primary Contact Phone Number *

Parent/Secondary Contact Name *

Secondary Contact Phone Number *

Camper Information: Age when camp starts *

Grade Completed During 2023-2024 School Year *

Does your child receive Adapted Physical Education services at school? *

Please list any other services your child receives at school. (Ex: tutoring, speech therapy, special education services)

Does your child have a mild intellectual disability, autism spectrum disorder, a language, learning disorder and/or physical disability? *

If yes to the previous question, please describe. *

Does your child have any of the following: Food Allergies? Health Concerns? Other considerations? None? Please describe below. *

Emergency Contact Information *

If you cannot be reached in the event of an emergency, please list the names an contact information for TWO local people (family, neighbors) who may assume temporary care of your child until you are available.

T-shirt Size for camper *

Please list the names (in addition to those listed above) with whom your child may leave camp (Ex. carpooling with another student's parent). *

Do we have permission to transport your child to the hospital if we cannot reach you by phone? *

Can the doctor on duty treat your child? *

If no, please list the name and contact information of the doctor that may treat your child. *

In case of an emergency, I (the parent or guardian) will be responsible for all bills incurred while receiving treatment and transportation. *

Yes (by checking this box you "electronically" sign and agree)

No medication of any kind will be administered during CHAMP Camp. Parents are welcome to come to the Kinesiology Gym to administer medication for their child/children. No medication may be brought to school by campers at any time. *

I understand and agree

Name of person providing information on this registration form. *

Relationship to Camper *

Consent Form - Permission for Use of Video and/or Photographs: I grant permission to Southeastern Louisiana University's CHAMP Camp to make videotapes, photographs, and/or sound recordings separately or in combination, of my child for educational and/or recruitment purposes. I also understand that these videotapes, photographs, and/or sound recordings may be used on the Southeastern web site. I understand that my child may be videotaped and/or photographed in learning events. Minors in photos and/or videos will be identified by first name only. All video/photo footage will remain in the property of Southeastern Louisiana University and College of Nursing and Health Sciences. When I electronically submit this, I am indicating that this page was read and that I am agreeing to the use of photographs, videotapes, and/or sounds recordings of my child for web or printed publication. *

Is there anything else we need to know about your child, or that you would like to share to help us have a safe, enjoyable, and successful CHAMP camp experience?

$85.00

Qty:

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CHAMP Camp Registration 2024