Camp Hands Up 2018 Registration Form **Please Note: Prices are changed and see on the bottom**

Transcription

1 Camp Hands Up 2018 Registration Form **Please Note: Prices are changed and see on the bottom** Participant Questions (Required) = * *First & Last Name *Date of Birth *Gender: Male or Female *Grade: * Address: *Address: Address 2: *City: *State/Province: *Country: *Zip/Postal Code: *Home Phone: VP or Voice or TTY Cell Phone: VP or Voice or TTY or Text *School Name: *T-Shirt: S or M or L or XL or XXL Emergency Contact and Medical Information *Family Doctor: *Doctor Phone: *Insurance Company: *Policy Number: *Emergency Contact Name:

2 *Emergency Contact Relationship: *Emergency Contact Main Phone: Emergency Contact Other Phone: *Emergency Contact Address: Medical History *Does your child have any medical, dietary, physical, or psychological condition/information that the camp staff any need to be aware of? YES No *Please explain any medical, dietary, physical, or psychological condition/information: *Please check all that apply: Asthma Bed Wetting (Current) Bee Sting Allergy Diabetes Fainting Heart Trouble Rheumatic Fever Seizures/Convulsion Sleep Walking Other None of the above Other Conditions: *Does your child have any of the following allergies: Food Insect bites/stings Medication Other None of these *Please explain food allergies:

3 *Please explain insect bites/stings reactions & treatment: *Please explain medication allergies: *Please explain other allergies: *Date of last Tetanus shot: *Is camper on any medication now? Yes No Please list any prescription medication that the camper will bring with them to camp: Medication and Reason: Dosage: Time: Medication and Reason: Dosage: Time

4 Medication and Reason: Dosage: Time: Medication and Reason: Any other medical conditions not mentioned: Activities that camper may NOT participate in: Are there any OTC (over-the-counter) medication you do not give permission for camp medical staff to administer.: Parent/Guardian questions *First & Last Name: *Home Phone: *Cell Phone: Gender: *Date of Birth: * Address: Electronic Waiver 2018 Medical Waiver and Emergency Information The Camp s insurance covers Accidents only and is secondary to your own coverage. To the best of my knowledge, this health history is correct and the person herein described has my permission to engage in all camp activities except as noted. I fully understand that after reasonable precautions are taken, there are certain hazards connected with the camp environment, and I release the TILIKUM and the Yakima Valley Association of the Deaf and camp staff from liability connected with camp activities, including loss of

5 clothing, hearing aids and personal items. Camp Hands Up does not provide health or accident insurance for campers. I understand I am responsible for all expenses associated with medical evaluation, treatment and transportation made on camper s behalf. I agree to release any pictures of my child for publicity purposes. I further agree to pay any property damage sustained at camp by my child. Authorization for treatment: In the event of an emergency, I hereby give permission to the medical personnel selected by the Camp Director to secure and administer treatment, including hospitalization for my child. I also hereby give permission for the camp medical staff to dispense OTC (over-the-counter) medication as needed to my child, except those noted on the registration form. Signature: Date Authorization for Treatment Please Note: Any prescription or over the counter medication must be in the original container and clearly marked. In the event of an emergency, I hereby give permission to the medical personnel selected by the Camp Director to secure and administer treatment, including hospitalization for my child. Signature: Date Required: Participant photo with color Payment Check Money Order Credit/Debit Card Payable to Camp Hands Up Your Name of Card Number Expires / Security Code Signature: Date:

6 REVISED and UPDATED of November 25, 2017 $ Full Payment (Sept 1 until April 30 th ) Late: $ after April 30 th $55.00 Deposit Payment will hold your place in camp with balance due before June 1 st. $ Deposit Payment (Others) Mail to: Camp Hands Up c/o Camp Director 1109 S. 7 th Ave Yakima, WA Have questions? Please contact to the camp director. deafkidrunner@hotmail.com or feel free to contact me: