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Student Release Form

The Student Release Form should be completed for EACH student ages 3–5. This form only needs to be submitted once per year for all campers, regardless of age, even if your child will attend multiple camps during the summer.

Student Release Form

Check one:(Required)

This is my initial Student Release Form submission

This is an update to my initial Student Release Form submission

Camper Name(Required)

First Last

Camp Name(s)(Required)

Current week or first camp attending

Parent/Guardian Information

Parent/Guardian 1: Contact Information

Name

First Last

Phone (home)

Phone (cell)

Phone (work)

Parent/Guardian 2: Contact Information

Name

First Last

Phone (home)

Phone (cell)

Phone (work)

Authorization for Release

COCA’s system only allows two authorized individuals (other than parents/guardians) to be listed. Contact COCA’s Registration Office if there are changes.

Authorized Individual 1

Person 1: Name

First Last

Person 1: Phone

Person 1: Relationship to Camper

Add or Remove from the List

Authorized Individual 2

Person 2: Name

First Last

Person 2: Phone

Person 2: Relationship to Camper

Add or Remove from the List

Parent/Guardian Signature

Signature

Date

Name

This field is for validation purposes and should be left unchanged.

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