CAMP FRIENDSHIP REGISTRATION FORM
_____ After School Care – Pepper Geddings Recreation Center (2017/18)
_____ Summer Camp/Camp Friendship – Pepper Geddings Recreation Center (2017)
Child #1: Name ___________________________ DOB: _________ Age: _______ Sex: _____ Grade: ______
Child #2: Name ___________________________ DOB: _________ Age: _______ Sex: _____ Grade: ______
Child #3: Name ___________________________ DOB: _________ Age: _______ Sex: _____ Grade: ______
Address: ___________________________________ City/State: _________________ Zip Code: ___________
Mother's Name: ___________________________________________ Birth Date: __________________________
Father's Name: ___________________________________________ Birth Date: __________________________
E-Mail Address: ________________________________________________________________________________
Persons Authorized to Pick Up: ____________________________________________________________________
Home Telephone Number: _______________________________________________________________________
Dad’s Place of Employment: ___________________________________________ Work #: __________________
Cell #: ___________________ Other #: __________________
Mom’s Place of Employment: __________________________________________ Work #: __________________
Cell #: ___________________ Other #: __________________
Emergency Contact: _____________________________________________________________________________
Emergency Phone Number: _______________________________________________________________________
Medical Conditions: _______________________________________________________________________
Medications: __________________________________________________________________________________
Allergies: ______________________________________________________________________________
Camp Friendship T-Shirt:
Youth Sizes:
S
M
L
Adult Sizes:
S
M
L
XL
If you would like to participate in these activities and need
disability-related accommodations, please contact Amy Elvis at 843-918-2290.
INSURANCE STATEMENT
***THIS MUST BE SIGNED FOR THE FORM TO BE RECEIVED BY STAFF***
I give my permission for my child to participate in the City of Myrtle Beach Recreation Division Program selected above.
I also grant permission to managing and/or program personnel to authorize and obtain medical care and treatment from
any licensed physician, hospital, or medical clinic, including major surgery, deemed necessary by a duly authorized
physician should the child become ill or injured while participating in Recreation Department activities, when neither
parent/guardian is available to grant authorization for emergency treatment. I hereby release the City of Myrtle Beach
from any liability arising from my child participating in this program. I also hold the above harmless and indemnified
from all claims. I understand and voluntarily consent to this agreement. ***
Parent/Guardian Signature _______________________________________________ Date _________________________
CAMP FRIENDSHIP
SWIMMING INFORMATION
While participating in the Youth Programs, your child will be swimming at the Pepper Geddings
Recreation Center Pool. This pool is four (4) feet deep at the shallowest depth and 12 feet deep where
the diving board is located. With this in mind, please put your child's name next to the statement
below which you feel best describes your child’s swimming ability:
___________ 1. I do not know my child’s swimming ability.
___________ 2. My child has had little or no swimming experience and would
probably be more comfortable in a lifejacket. (Non-Swimmer)
___________ 3. My child has had limited swimming experience. Can swim
three (3) feet or less. Prefers playing at or near the pool’s edge
or pool stairs. Possibly needs a lifejacket. (Novice Swimmer)
___________ 4. My child is fairly comfortable in the pool. Can swim with
his/her face in the water. Has had some swim lessons and is
fairly confident with swimming and safety skills at any depth.
(Average Swimmer)
___________ 5. My child is very comfortable and familiar in any depth of water.
I am confident about his/her swimming ability in any area of the
pool. (Good Swimmer)
Additional Comments: _______________________________________________________________
Parent’s Signature: _______________________________________ Date: ____________________
REDUCED FEE CRITERIA AND
APPLICATION FOR YOUTH PROGRAMS
Parents must be able to show proof of one of the following:
1. The family is now receiving food stamps.
2. The family is now receiving welfare compensation.
3. The family is now living in public housing.
RECEIVING MEDICAID BENEFITS DOES NOT QUALIFY YOU
FOR REDUCED RATES. RATES ARE SUBJECT TO CHANGE AS
MANDATED BY MYRTLE BEACH CITY COUNCIL.
Name: ________________________________________________________________________
(Parent/Guardian - Please Print)
Address: _______________________________________________________________________
Phone Number: (Home) ___________________ (Work) _________________
Describe Your Household: ____ Working Single Parent ____ Two-Parent Home, Both Working
Place of Employment: ____________________________________________________________
Spouse’s Place of Employment: ____________________________________________________
Are you receiving assistance from federal, state, or local program? Explain: ________________
______________________________________________________________________________
Names/Ages of children in your home, attending the program: ___________________________
______________________________________________________________________________
Briefly explain in the space below why you need a reduced fee in our program.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I have read and answered all questions, correctly, to the best of my knowledge.
__________________________________
Signature
_________________
Date
======================================================================
For office use only:
_________ Approved
_________ Declined - Reasons