cAMPer Info



Medical Information

  • Registrant has known physical disability or illness which might interfere with their participation in strenuous activity

  • Registrant has severe allergies or reactions to drugs or medicines.

  • Registrant has severe allergies or reactions to food.

  • Registrant has emotional/social needs that would be helpful for us to be aware of.

  • Registrant has emotional/social needs that would be helpful for us to be aware of.


A health form documenting that your child received a physical within two years of the child's start date at AMP is required and must be submitted PRIOR to your child's attendance this summer. Any form provided by your child's doctor's office is acceptable; if you need to provide a form to the doctor to complete you may use this:
https://portal.ct.gov/-/media/SDE/School-Nursing/Forms/EC_HAR.pdf

As parent/legal guardian, I give permission for my child to attend Summer @AMP. I understand that personal injury can and may occur to my child, and I hereby authorize Summer @AMP staff and volunteers, or another appointed person, to seek and consent to emergency medical attention for my child as needed; and I further agree to be liable for and to pay all costs incurred in connection with such medical attention. I hereby release and hold harmless Summer @AMP, the American Mural Project, its officers, directors, employees, agents, and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by my child while participating.
I understand that the American Mural Project may take photographs and/or videos, and make electronic representations and/or sound recordings during my child’s program participation. I grant to the American Mural Project the right to use my child’s likeness, image, voice, and appearance, as embodied in said photographs, videos, electronic representations, and/or sound recordings. This grant includes without limitation the right to edit, mix, or duplicate and to use or re-use said photographs, videos, electronic representations, and/or sound recordings. The American Mural Project or its designee shall have complete ownership of said photographs, videos, electronic representations, and/or sound recordings in which my child appears or is heard, including copyright interests, and I acknowledge that neither I or my child has any interest or ownership in said photographs, videos, electronic representations, and/or sound recordings or its copyright. I also grant to the American Mural Project and its designee the right to broadcast, exhibit, market, sell and otherwise distribute said photographs, videos, electronic representations, and/or sound recordings, for commercial or non-commercial television or theater, closed-circuit exhibition, home video distribution, or any other purpose that the American Mural Project or its designee in their sole discretion determine, including, without by way of limitation, educational, training, and promotional purposes in print, online, and via social media, but that my child’s identity will not be disclosed. I further waive the right to approve the final edited or unedited versions of said photographs, videos, electronic representations, and/or sound recordings. I also expressly release, forever discharge and indemnify the American Mural Project and its officers, directors, employees, agents, and designees from any and all claims, demands, rights, promises, damages, and liabilities arising out of or in connection with the use or distribution of said photographs, videos, electronic representations, and/or sound recordings, known and unknown, arising out of, or in any way connected with, the above granted uses and representations, including, but not limited to any claims for invasion of privacy, appropriation of likeness, or defamation. I specifically waive any right to any compensation I or my child may have for any of the foregoing.

Parent/Guardian 1 Info

Parent/Guardian 2 Info


Emergency Contact Info



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Billing Information

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