EMS Safety Camp Registration Form

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Grade

Gender

MaleFemalePrefer not to disclose

T Shirt Size

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name

First NameLast Name

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

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.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by McDowell County Emergency Services during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless McDowell County Emergency Services and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against McDowell Emergency Services including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, 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.

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.

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.

Date

Signature

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Payment

Cost: $25.00/Child

Online: You will be redirected to the online payment option once you submit the registration form. Click on FINANCE PAYMENTS>Select County & State>Select SAFETY CAMP>Enter your information and the total due. Service fee for online pmt.

Mail: Checks made payable to McDowell EMS can be mailed to 129 Barnes Rd. Marion, NC 28752

In-Person: Check or cash payment can be made in person at McDowell Emergency Services Headquarters located at 129 Barnes Rd. Marion, NC 28752

Summer Camp Registration

Camper Information