CompanyThis field is for validation purposes and should be left unchanged.Please fill and submit this form for all minors in the Children's Program who will be attending Northern Pines without a legal guardian (ages 0–going into third grade). Please only submit one form per child. Please visit the Parent Portal for additional forms.Email(Required)Please provide an email address so we can send you a copy of your submission. Enter Email Confirm Email Section One: Child's InformationChild's Legal Name(Required) First Last Birth Date Month Day Year Child's Class while at Camp:Please select the grade your child will enter this fall, after camp. Please visit the Parent Portal to access the form for your older children.Sprouts (0–12 Months)Seedlings (12–24 Months)Birch (Two Years)Cedar (Three Years)Maple (Preschool 1)Oak (Preschool 2)KindergartenFirst GradeSecond GradeThird GradeGender Boy Girl Which week the child is attending?(Required) Week 1 Week 2 Child's Primary Home AddressIf their address is the same as a previously submitted form, you can list that child's name instead. Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child's Health InformationPlease share any special health considerations which our staff should be aware. These include allergies or other conditions which might need attention at the conference. List any medication to be taken while at the conference.Section Two: Parent/Guardian infoAdditional Siblings | Parent/GuardianIf this information is the same as a previous submitted form, please provide that child’s name and then you can skip this section.Parent or Guardian #1Name (Parent/Guardian #1) First Last Cell Phone Number (P1)Relationship to Child (P1)Address (P1) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent or Guardian #2Name (Parent/Guardian #2) First Last Cell Phone Number (P2)Relationship to Child (P2)Address (P2)Leave blank if the same address as parent/guardian #1 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Section Three: Emergency ContactsWho should we contact if we are unable to reach the child's parents at above phone number(s)?Additional Siblings | Emergency ContactsIf this information is the same as a previous submitted form, please provide that child’s name and then you can skip this section.Name (EC1) First Last Cell Phone Number (EC1)Relationship to Child (EC1)Is this adult also attending Northern Pines? (EC1)Specifically this summer during the same week as this child. Yes Yes, on Staff No Name (EC2) First Last Cell Phone Number (EC2)Relationship to Child (EC2)Is this adult also attending Northern Pines? (EC1)Specifically this summer during the same week as this child. Yes Yes, on Staff No Section Four: Insurance InformationAdditional Siblings | InsuranceIf this information is the same as a previous submitted form, please provide that child’s name and then you can skip this section. However, please provide the Member ID specific to this child.Medical Insurance ProviderInsurance Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy/Group/Account #:Member ID #Name of Insurance Holder First Last Relationship to Insured Child:Medical ReleaseReasonable effort will be made to reach you in the event of an accident or illness involving your child who requires medical attention. If you cannot be reached, your signature on the following release will ensure prompt care.Consent(Required)As parents/guardians of the student named on this release, we authorize the staff, officers, or directors of Northern Pines of Minnesota, Inc. or any licensed physician or nurse who may be in attendance to act as our agents in arranging for and consenting to any medical care or attention which may be required or seem appropriate while he/she is at a Northern Pines conference activity. It is understood that this authorization is given in advance of any specific medical attention being required, and is given to provide Northern Pines and its representatives with the authority to act on our behalf. I agree to the privacy policy.Signature(Required)Today's Date MM slash DD slash YYYY
