Pine Grove Association MAGIC Camp Registration Form

Child
Name
Gender

MaleFemale
T-Shirt Size
School Name
Grade
Birth date

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Parent/Guardian - Contact Information

Parent/Guardian #1
Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Occupation
Employer
Parent/Guardian #2
Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Occupation
Employer
Emergency Contact Information – Alternate Pickup/Release

Emergency Contact #1
Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Relation to child
Emergency Contact #2
Name
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Relation to child
Please list those people in addition to parents/guardians who are permitted to pick up your child:
1 2
Medical Release Information

Insurance Information
Policy Number
Name of Health Insurance Provider
Primary Physician
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Hospital
Preference

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma,Seizures).

	Medical Problem	Required treatment	Should paramedic by called?

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

YesNo
If yes, explain:
Is your child allergic to any type of food or medication?

YesNo
If yes, explain:
Does your child require a special diet?

YesNo
If yes, explain:
I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event
my child is injured or becomes ill.

The information provided is accurate and I understand that the Pine Grove Association staff or volunteers will not dispense any medication to any child. The Pine Grove Association will not be liable for any reaction to medication dispensed by the child, parent or guardian on the Pine Grove Association premises.

I understand that the Pine Grove Association, Inc. will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Photo Release
I hereby give permission for my child to be photographed or video taped during the Pine Grove Association, Inc. MAGIC Camp. I understand the photos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper, social medial and on the internet. I do not expect compensation and that all photos are the property of Pine Grove Association, Inc. and its affiliates.

Transportation Release
I hereby give permission for the transportation of my child for official Pine Grove Association, Inc. activities by modes of transportation agreed to by the camp organizers.

Field Trips
I hereby give permission for my child to attend field trips/outings planned by the Pine Grove Association.

I agree that the Pine Grove Association and its officers, directors, employees, and volunteers are not liable for any accident, injury, medical expenses or other damages that may be incurred by my child on the premises of the Pine
Grove Community Center or other facility used by the Pine Grove Association, or during any activity sponsored, or conducted by the Pine Grove Association. I further agree to indemnify, defend and hold harmless the Pine Grove Association, its officers, directors, employees or volunteers, from any and all causes of action that may be brought against them as a result of any injuries or damages incurred by my children while participating in any Pine Grove Association.

The Pine Grove Association is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

By signing below, I confirm and state that I have read and agree to all the terms listed on this form.
Guardian Signature:

Clear
Date

MonthDayYear
Date
Printed Name of Parent/Guardian:
Should be Empty:

Child

Parent/Guardian - Contact Information

Parent/Guardian #2

Emergency Contact Information – Alternate Pickup/Release

Emergency Contact #2

Medical Release Information