Camp Capri Registration

    Youth Information











  • Arts Participation

  • Participation Permission

  • By checking the box below, I give permission for my child to participate in Camp Capri.
  • Photo/Video Permission

  • By checking the box below, I give permission for my child I give permission for my child to be photographed and/or videotaped within the context of Camp Capri. I also give permission for PCYC to use
    any photograph/video segment for the purposes of advancing the mission of the organization.
  • Phone Numbers, Email, Emergency Contact

 

Health Information

    Clinic/Physician Information

  • Medical Information

  • Does your child have:

  • By checking the box below, I give permission for my child to be seen for health services in the clinic at Plymouth Christian Youth Center and give permission for staff to transport my child to receive emergency medical attention if needed.

 

Verification

 

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,         (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)   Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

(2) Fax: (202) 690-7442; or
(3)   Email: program.intake@usda.gov.