Fox Kits
Sundays 2021-22 - Registration Form
Student
*
First Name
Last Name
Age
*
Parent/Guardian
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Emergency Information
Emergency Contact
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
*
-
Area Code
Phone Number
Medical Information
Does your child have any allergies or medical conditions that our staff should be aware of?
*
Health Care Providor
Medical Identification Number
Name and Phone # of Child's Physician
Is there anything you would like to share about your child to help them have a successful time at Flickers?
Permission to vaccinate or inoculate (for anti-venom or epi-pen for allergic reaction ONLY)
YES
AUTHORIZATION TO CONSENT TO TREATMENT OF MINORI do hereby authorize ‘FOPR’’ Staff, to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the California Medical Practice Act, whether such diagnosis or treatment is rendered during an “FOPR” outing by said health care provider at the outing location, the provider’s office, a hospital, or other location. This authorization also applies to dental care under a duly licensed dentist. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the afore mentioned physician in the exercise of his/her best judgment may deem advisable; and neither said agent or any organization involved assumes any financial responsibility for exercising this action. The undersigned also releases “FOPR”, and its agent, from all claims which may develop or accrue to me, or the minor for whom this authorization is intended to benefit, on account of, or reason by of, any injury, loss, or damage which may be suffered by me or the minor as a result of the exercise of this consent, and I hereby assume and accept the full risk and danger of any injury; hurt or damage that may occur as a result of the use of exercise of this consent. This authorization is given pursuant to the provision of Section 6910 of the Family Code of California and shall remain effective until revoked in writing and delivered to said agent(s).
YES
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Fox Kits - 2022-SUN
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300.00
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