Theater Camp Registration Form

Emergency Contact Information
Name of Emergency Contact

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relation to Student
Confirmation

I hereby declare that I give my full express consent to let my child be given immediate treatment by any qualified medical personnel in circumstances which may need immediate attendance and care.
Clinic / Hospital
Name of Family Doctor

First NameLast Name

Medical Information
In case the parent/guardian is out of reach at the time of emergency, with consent of the latter, we will exercise the required diligence needed to have the athlete treated by an E.R Physician. In this regard, we would like to get to know any precautions that we need for the athlete
Any Allergies to Medicine and Antibiotics?

Parental/Guardian Consent
Waiver

I am aware that if an accidental injury or harm happens, and I assume any and all possible risk that may cause injury, illness, or death arising to such activity. I agree to waive my right to pursue any claim against St Michaels Episcopal Church of this event.
I concent to my child's image or likeness being used for publication and social media purposes.

YesNoTalk to me more
Signature of Parent / Guardian

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Name

First NameLast Name
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Emergency Contact Information