Adventure Therapy Camp Registration and Consent Form

Chugachmiut Adventure Therapy Camp Registration
If you have any questions, please contact Becks Jacobs @ becksj@chugachmiut.org or (907) 230-5184
Parent/Guardian Information
Parent/Guardian Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email
*Important camp information and updates will be sent to the email address on file.
2nd Parent/Guardian Name (Optional)

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Information
Child's Name

First NameLast Name
Child's Gender
Child's Date of Birth

MonthDayYear
Child's Age
Is your child currently on Medicaid or Denali KidCare?
Is your child Alaska Native or American Indian
Any Known Allergies?
If yes, please list below:
Any Medications?
If yes, please list below:
Other Known Conditions *If none, please type N/A
Emergency Contacts
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
By submitting this form, I acknowledge that:

The information provided is accurate and complete. Chugachmiut Behavioral Health staff will be reviewing this registration application to determine eligibility and reaching out to schedule a behavioral health assessment if participant is not an established client.
Guardian Name

First NameLast Name
Signature
Should be Empty:

Chugachmiut Adventure Therapy Camp Registration

Parent/Guardian Information

Child Information

Emergency Contacts

By submitting this form, I acknowledge that: