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Birthdate
Single choice
Male
Female
Shirt Size
sm
med
lg
xl
2xl
kids sm
kids med
kids lg

PARENT/GARDIAN

Emergency Contact Information

MEDICAL INFORMATION

Is the applicant currently taking any medication?
Yes
No
Does the applicant have any allergies?
Yes
No
Please select the activities the applicant is interested in (check all that apply):

Additional Information

Does the applicant have any dietary restrictions?
Yes
No

Consent and Agreements

Parental Consent:

I, the undersigned, give permission for my child to participate in the IRTC Summer Camp activities.

Medical Consent:

In the event of an emergency, I authorize the camp staff to seek medical treatment for my child.

Photo/Video Release:

grant permission for my child’s photos/videos to be used for promotional purposes by IRTC.

Date and time
:
Contact Us

323 East 53rd Street

Brooklyn, NY 11203

Connect with us

Phone: (718) 940-7499

Registered Charity Number : 20-3419400

© 2024 by Community Concerns Network Inc.

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