Park City Kidz Camp

Summer Camp Registration

July 8- August 2, 2024
Participant Information
Child's name*

First NameLast Name
Birth Date*

MonthDayYear
MaleFemale
GRADE ENTERING IN SEPTEMBER 2024
CHILD'S SCHOOL
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Mail Address
Primary Spoken Language at Home:
YESNO
If yes please give a short description:
Hispanic/LatinoWhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsian & WhiteOther
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail*
example@example.com
Does your child have any musical gifts you would like to share with us?*
T-shirt size*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is the child prescribed an inhaler? If yes, please explain any instructions.*
HOW MANY PEOPLE LIVE IN THE HOUSEHOLD INCLUDING ALL ADULTS AND CHILDREN?
$0-$9,999$10,000-$19,999$20,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$59,999$60,000-$69,999$70,000-$79,999$80,000-$89,999$99,000-$99,999
Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Park City Initiative Corp., and its affiliates including Directors, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Signature

Clear
Photo Release Form for Children and Youth

I agree that Park City Initiative Corp. To allow photograph and live-record of my child/dependent’s likeness and activities (Images)[1] during camp activities. I grant the following rights to Park City Initiative Corp. permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the ministry website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge Park City Initiative Corp. from any and all claims arising out of the use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have the legal capacity to sign the release.

[1] Image means all photographs, film, live recording, or other recordings taken of you as part of the Shoot and off-site Filming if needed.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Week 1: M. July 8- F. July 12Week 2: M. July 15- F. July 19Week 3: M. July 22- F. July 26Week 4: M. July 29- F. August 2
Should be Empty:

Summer Camp Registration