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2. 1st Participant Information
4. First Name*
5. Last Name*
7. Preferred Name
8. Date of Birth*
   Date of Birth
9. Age of Child*
   -- Select One --56789101112131415

   Child must be 5 years old by the first day of camp.
11. Health Conditions, Allergies, Physical Restrictions, Behavior Plan, Medications
13. See below for descriptions and please mark Yes or No for each:
15. Signing In and Out*

    1. Yes

    1. No
17. Permission to Record & Photograph Child Participating in Activities*

    1. Yes

    1. No
19. Waiver of Liability & Permission for Medical Consent*

    1. Yes

    1. No
21. Permission to Administer Questionnaires to Participants*

    1. Yes

    1. No
25. 2nd Participant Information
27. First Name
28. Last Name
30. Preferred Name
31. Date of Birth
    Date of Birth
32. Age of Child
    -- Select One --56789101112131415

    Child must be 5 years old by the first day of camp.

34. Health Conditions, Allergies, Physical Restrictions, Behavior Plan, Medications
36. See below for descriptions and please mark Yes or No for each:
38. Signing In and Out*

    1. Yes

    1. No
40. Permission to Record & Photograph Child Participating in Activities

    1. Yes

    1. No
42. Permission to Administer Questionnaires to Participants

    1. Yes

    1. No
44. Waiver of Liability & Permission for Medical Consent

    1. Yes

    1. No
48. 3rd Participant Information
50. First Name
51. Last Name
53. Preferred Name
54. Date of Birth
    Date of Birth
55. Age of Child
    -- Select One --56789101112131415

    Child must be 5 years old by the first day of camp.

57. Health Conditions, Allergies, Physical Restrictions, Behavior Plan, Medications
59. See below for descriptions and please mark Yes or No for each:
61. Signing In and Out*

    1. Yes

    1. No
63. Permission to Record & Photograph Child Participating in Activities

    1. Yes

    1. No
65. Permission to Administer Questionnaires to Participants

    1. Yes

    1. No
67. Waiver of Liability & Permission for Medical Consent

    1. Yes

    1. No
71. Parent(s)/Guardian(s) Name(s):*
73. Address1*
75. Address2
77. City*
78. State*
79. Zip*
81. Phone Number(s) that would like to receive program text messages and updates
83. Cell Phone Service Provider
85. Email Address*
89. Emergency Contact 1 - Name*
90. Emergency Contact 1 - Phone #:*
92. Emergency Contact 2 - Name*
93. Emergency Contact 2 - Phone #*
95. Emergency Contact 3 - Name*
96. Emergency Contact 3 - Phone #*
100. Signing In & Out*

     I understand that my child needs to be dropped off and picked up by an adult listed on this emergency contact form. I understand that my child is unable to walk home alone unless special arrangements have been made with a CAC Coordinator by calling734/394-5430.

     1. Yes
     2. No
102. Permission to Record & Photograph Child Participating in Activities*

     I hereby release to Canton Township rights to my child’s image, likeness, and the sound of their voice as recorded or photographed. I understand this recording or photograph may be edited and placed in publications, and thereafter the recording or photograph may be otherwise available. I agree to release, discharge, and save harmless Canton Township, including its representatives or designees, from any legal proceedings which may arise in relation to the conditions of the above paragraph.

     1. Yes
     2. No
104. Permission to Administer Questionnaires to Participants*

     I hereby give Canton Township my permission to administer questionnaires to my child for the purposes of improving future programs. I understand that the information collected from my child will remain anonymous and that my child’s identity will not be revealed in relationship to the survey.

     1. Yes
     2. No
106. Waiver of Liability & Permission for Medical Consent*

     In consideration of Canton Township permitting my child to participate in Canton Activity Crew (C.A.C.) events off-site and providing transportation to and from said events, I, on behalf of myself, my child, my heirs, successors and assigns, hereby release Canton Township, its elected and appointed and officials, and its employees, volunteers, and agents, as well as the representatives of any other organization connected with this event, from any and all claims for liabilities or damages for any and all property damage or injuries which my child may suffer while taking part in any activities connected with this event. In case of injury, and I am unable to be contacted by your staff, I give my consent to have medical treatment administered to my child if deemed necessary by a physician and understand I shall be liable for any costs associated therewith.

     1. Yes
     2. No
108. Parent/Guardian Signature*
     Type Name for Signature
109. Date*
     Date
111. By checking "yes", I certify that the information contained in this application is accurate. I agree:*

     1. Yes
     2. No
113. I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the signer, and further that I agree to the above Terms of Acceptance. *

     1. Yes
     2. No
Leave This Blank:


115. 1. Receive an email copy of this form.
116. Email address

     This field is not part of the form submission.

117. Submit

* indicates a required field