Lake Havasu City Parks & Recreation
Camp Registration Form
Camp Location: ______________________________________________
Participant’s Name (last name, first name): ______________________________________________________
Date of Birth: ____ / ____ / ____ Age: ______ Grade: ______ Gender: ______
Address: ________________________________ City: ________________ State: ______ Zip: __________
Parent/Guardian Name: ________________________________ Phone: _____________________________
Parent/Guardian Name: ________________________________ Phone: _____________________________
Is the participant permitted to walk home from the program? Yes __ No __
If yes, please indicate the time the participant is permitted to leave the program: _______________ PM
Participant will not be released to anyone whose name does not appear on this form. Identification is required
when picking up the participant. The following people, in addition to the parent/guardian (s) listed above, are
authorized to pick up the participant from the program. Any of the below listed people may be contacted in
case of an emergency. It is the responsibility of the parent/guardian to pick up the participant on time at the
end of the program if the participant is not permitted to walk home. Lake Havasu City reserves the right to
contact the Police Department if the participant is not picked up in a timely manner.
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
Name: ________________________________ Relationship: _______________ Phone: _______________
All changes to this form must be made through the Lake Havasu City Aquatic Center. This form may be
modified or changed by the below parent/guardian.
Parent/Legal Guardian: ______________________________________________ Date: ________________
Signature
______________________________________________
Print Name
