2. COMPLETE ONE FORM PER CHILD
4. TOJ HURRICANE CAMP REGISTRATION
   COMPLETE ONE FORM PER CHILD The Recreation Department will offer a day camp for school aged children K-8th grade at the Jupiter Community Center from 8am-5pm during the weekdays immediately prior to or following a tropical storm, hurricane or other natural disaster that has resulted in the closing of Palm Beach County Schools. However, camp hours may vary upon the Town work schedule mandated by the Town Manager. Camp will be available once the Community Center is deemed safe for use, when duty designation “B” employees are required to report to work and will not be held during the times that the Town is closed to employees. This camp will be free of charge to all children of Town of Jupiter employees (does not apply to grandchildren, nieces/nephews, neighbors or friends).
6. CHILD'S INFORMATION
8. Child's Last Name*
9. Child's First Name*
11. Child's Date of Birth*
12. Child's Age*
13. Child's Current Grade*
17. PARENT INFORMATION
19. Primary Guardian (First & Last Name)*
20. TOJ Department*
22. Primary Guardian Cell Phone*
23. Primary Guardian Work Number/Extension*
25. Primary Guardian TOJ Work Email*
26. Primary Guardian Alternative Email*
28. Secondary Guardian (First & Last Name)
30. Secondary Guardian Cell Phone
31. Secondary Guardian Work Number
33. Secondary Guardian Email Address
37. Does your child have any allergies?*

    1. Yes
    2. No
38. If yes, please specify:
40. Does your child have any special needs, physical limitations or behavioral diagnosis?*

    1. Yes
    2. No
41. If yes, please specify:
43. Does your child take any medications?*

    1. Yes
    2. No
44. If yes, please specify:
46. Is there a visitation order or other Florida court order barring either parent from removing the child during the camp day or coming into contact with the child? If YES, provide camp director with a copy of the Florida court order.*

    1. Yes
    2. No
50. AUTHORIZED PICK-UP
    Provide the name(s) of up to 2 person(s), other than the parent, allowed to pick up the child. All parent's and authorized pick-ups MUST be prepared with a photo ID in order to sign out children.
52. Pickup #1 (Include first and last name):*
53. Pickup #2 (Include first and last name)
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field