Brown Girls Climbing Registration Brown Girls Climbing Program Selection Team Program Ascent Team (ages 7-9) Peak Team (ages 10+) Competition Team (ages 9+) 2024 Summer Camp Series Selection Epic Adventures Rock & Water (June 17-21) Mini-Adventures All Access Camp (July 16-19) Base Camp Adventures (July 22-26) Section 1 | Participant Information Participant's Name * First Name Last Name Preferred Name Gender * she/her he/him them/they GNB GNC 2 Spirit Other DOB * MM DD YYYY Is the participant of the Global Majority? * Person of Color, BIPOC, Afro-Diaspora, Indigenous, First Nations, Womxn of Color, Jews of Color, Asian, Korean, Pacific Islander, Latinx or another color under the rainbow if diversity? Yes No Racial Ethnicity * Please describe racial identity Primary Family Composition * Describe identities of in-home(s)/nuclear family Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Participant Email Address * Does participant have an email address? Participant Cell Phone Number Does participant have a cellphone Primary driver to practice (###) ### #### School/Learning Program Name of school for participants in a school program. Section 2 | Parent/Guardian Information Parent/Guardian Name * Please complete for participants 17 years old or younger. First Name Last Name Mailing Address (if different) complete if different from participant Address 1 Address 2 City State/Province Zip/Postal Code Country Primary phone * (###) ### #### Secondary phone (###) ### #### Parent/Guardian Please complete information for additional parent/guardian/family First Name Last Name Parent Phone * (###) ### #### Secondary Phone (###) ### #### Emergency Contact * List an emergency contact First Name Last Name Emergency Contact #1 Phones * (###) ### #### Emergency Contact Phone #2 (###) ### #### Section 3 Health Information Please take a moment to complete these important questions. Personality * Introvert Extrovert Cautious Risk-Taker Assertive Academic Competitive Artistic Previous Injuries * Has participant had an previous injuries? None Neck Back Shoulders Extremities Broken Bones Allergies Does participant have any allergies? None Animal Food Environmental Medical Allergy Severity and Symptoms What is the reaction and treatment to allergy encounter? Is participant aware of treatment and do they carry medical aid? Visual Impairments * None Wears glasses/contact for corrective vision Color Blind Depth Limitations Partial Blindness Blind Dietary Restrictions None Gluten Free Dairy Free Nut Free Vegetarian Vegan Handedness * What is the dominate hand Right Hand Left Hand Ambidextrous Cross Dominance No/Limited Motor Function Please share effective support techniques during vulnerable and challenging times. * Please share learning milestones in your child's life Section 4 Medical Information Please complete insurance information Policy or Certificate No. * Insurance Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Phone * (###) ### #### Primary Care Physician (PCP) * PCP phone * (###) ### #### Preferred Hospital/ER * Questions or Comments? Household Administrator/Communicator/Logistics Guru * Please help us communicate effectively! Who will be the point person in the family to communicate about camp? (Note: the point person is not always the person registering) Who should we include on communication threads? Registering Person Primary & Secondary Contact Multiple parties (this can include co-parents, extended family, blended families, childcare, drivers, etc.) Please check all forms of social media you consent TayloredFit Solutions to using and being used for this participant. Tayloredfit Solutions Facebook Tayloredfit Solutions Instagram Tayloredfit Solutions Website/Public Newsletters Filmaker, project Pallavi Somusetty movie/filming, interviews (Sponsor) Sports Basement (Sponsor) GoPro (Sponsor) Evolv Climbing (Sponsor) Organic Climbing Thank you for taking the time to complete this form! After submission, you will be directed to payment. A (non-refundable) deposit or Partial Payment to Payment in Full is due at time of registration Thank you for registering. We have received your information and will be in touch within 24 hours. Next step, complete payment.
