Changing the World Children Camp

Changing the World Children Camp Registration

PARTICIPANTS EMERGENCY INFORMATION
Dear Parent/Legal Guardian

In order to provide the best possible medical care for your child in the event of an injury or emergency, a medical record will be established for your child. If you're child should become injured or have an emergency while participating in this camp, this record will provide important information about them. Please complete and sign as indicated.
Participants Information
Participant's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*

Area CodePhone Number
Work Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
Insurance Information
Primary Insurance Company*
Policy/Group #*
Secondary Insurance Company
Policy/Group #
Known Allergies/Medical Conditions *If None, type N/A in the box below*
We, the undersigned participant and Parent/Legal Guardian, have read this document and understand all of the expectations for participating in the "Changing the World Children Camp".
Signature of Parent/Legal Guardian*
Signature of Participant*
ID #
Date*

MonthDayYear
Date

WAIVERS
PARENT/GUARDIANS FULL NAME*
PARTICIPATION AUTHORIZATION
I hereby grant permission for my CHILD to participate in Changing the World Children Camp which is indicated by my signature below. I hereby confirm, I have been informed by the Camp's Representative(s) the nature of this Camp as well as received, read, and understand the information in orientation given to me. I have had an opportunity to ask questions.
Signature of Responsible Person*
Signature of Responsible Relationship*
Date Signed*

MonthDayYear
Date
EMERGENCY CLAUSE

In the event I cannot be reached in an emergency, I hereby give my permission to staff members of the World Children Camp to secure proper medical care for my child as deemed necessary. This permission extends from minor first aid treatment to (under a doctors order) hospitalization injections, anesthesia, and other medical procedures deemed necessary.
Signature of Responsible Person*
Signature of Responsible Relationship*
Date Signed*

MonthDayYear
Date
MEDIA RELEASE

I herby grant permission to use, reproduce, edit, and/ or publish photographs and/ or video that may pertain to my youth- including their image, likeness and/or voice. I understand that this material may be used in various publications, public affairs releases, recruitment materials, broadcast public service advertising (PSA's) or for other related endeavors. This material may also appear on the Organization Internet Web Page, Facebook page, and etc. This Authorization is continuous and may only be withdrawn by your specific act of cancelation of this Authorization in writing. I acknowledge that since my child's participation is this camp is voluntary, therefore we will not receive any financial compensation.
Signature of Responsible Person*
Signature of Responsible Relationship*
Date Signed*

MonthDayYear
Date
STAFF ALERTS

Please list any Behavioral Problems, Diet Restrictions, Medical Conditions, or any other important information for our staff to know. If none, type N/A in the box below.

Changing the World Children Camp Registration

Dear Parent/Legal Guardian

Insurance Information

CHILDREN REGISTRATION FORM

CHILD INFORMATION

WAIVERS

PARTICIPATION AUTHORIZATION

EMERGENCY CLAUSE

MEDIA RELEASE

STAFF ALERTS

CHANGE YOUR WORLD SUMMER CAMP