Camper Information
emergency medical authorization, release of liability, and indemnity
agreement |
| Camper's Last Name
|
First Name
|
Age
|
Grade, Fall 2011
|
| E-mail address for confirmation
|
Home Address
|
City
|
State
|
| Zip
|
Current School
|
Home phone
|
Grouping Requests
|
| Parent/Guardian Name 1
|
Address (if different from above)
|
Cell Phone
|
Business phone
|
| Parent/Guardian Name 2
|
Address (if different from above)
|
Cell Phone
|
Business phone
|
|
|
Credit Card Type
|
Card Number (numbers only)
|
Name on card:
|
Expiration date:
|
|
|
| Contact Information for person who will care for child in an emergency if neither parent/guardian can be reached: |
| Name
|
Phone
|
Alternate Contact
|
Alternate Phone
|
|
|
List special health considerations related to child (also provide written directions directly to Sarah Jacobs, Camp Director): |
|
In the event that neither parent/guardian can be reached and emergency medical treatment is required, please name a medical doctor who should be consulted: |
| Name of Doctor
|
Phone
|
If parents/guardians or
doctor cannot be reached and emergency medical treatment is required,
the camper will be taken to the nearest emergency facility unless
other instructions provided herewith are to be followed:
|
|
|
|
| I hereby give my permission for
to attend Arts at Laguna 2011. |
I understand that the program will include on-campus and off-campus activities using school vehicles. The school agrees to take responsible precautions to provide for the safety and welfare of
.
|
Neither the camp, the school, the employees, the instructors, nor the counselors shall assume responsibility for accidents, injury, or illness. In the event of injury or illness that requires medical attention and services, the school shall first attempt to notify the camper's parents or designated agent using the information provided above. However, if emergency medical services are needed, the school, its employees, and staff are authorized to proceed to obtain medical services.
The undersigned permits Arts at Laguna to use his/her child's photographic likeness in media presentations or publications relating to the camp, unless the undersigned submits to the program director a written request to withdraw this permission.
|
| By checking the boxes below, the parents/guardians agree
to release, indemnify, and hold harmless Laguna Blanca School
and trustees, its agents and employees, officers and staff, and agrees
to pay for all medical expenses. |
Check here
|
Parent/Guardian Name 1
|
Date
|
|
Check here
|
Parent/Guardian Name 2
|
Date
|
|