James River Association Upper James River Summer Camps

3. Caretaker Information

Primary and Secondary Caretaker
Primary Caregiver First and Last Name *

First NameLast Name
Relationship to Camper*
Primary Caregiver Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Caregiver Phone Number (Mobile preferred)*

Area CodePhone Number
Secondary Caregiver First and Last Name

First NameLast Name
Secondary Caregiver Phone Number (Mobile preferred)

Area CodePhone Number
Secondary Caregiver Email Address
example@example.com
Emergency Contacts

Other than Caregivers, who will be contacted first in case of emergency.
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Relationship*
Emergency Contact #1 Phone*

Area CodePhone Number
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Relationship*
Emergency Contact #2 Phone*

Area CodePhone Number
Click 'Next' to continue to the Medical and Health Information.

4. Medical and Health Information
Camp staff do not distribute or administer medications, and campers should not bring medications with them to camp. If a camper has a medical condition that may require medication or emergency intervention, families must notify us in advance so we can determine whether the camper can be safely supported within the scope of the program. Emergency medications such as inhalers or EpiPens may be permitted only with prior approval and clear communication with camp staff.
Please list any known allergies or health conditions. If an allergy or health condition, please give details of the condition/reaction and what staff need to do in the case of a reaction.
Accessibility and Support Needs
YesNoPrefer not to say
What accommodations help your camper be successful?
Anything else staff should know to support your camper?
Click 'Next' to continue to the waiver information.

6. RELEASE AND WAIVER OF LIABILITY

All of the above information is to the best of my knowledge, correct. I understand that participation in the James River Association (JRA) activities is entirely voluntary. I understand that the JRA event may involve “hands on” activities such as planting trees, using equipment, boating, and or being in shallow water; and I understand the risks and dangers involved in the above-named activities. I know and understand that unanticipated
dangers might arise. I hereby release JRA from any responsibility for injury which might occur as a result of participation in JRA activities.

I give permission and authorize JRA personnel to carry out such emergency diagnostic and therapeutic procedures as may be necessary for me/my child, and also permit such treatment procedures to be carried out at and by the local hospital(s) for me/ my child in the event of an emergency. I understand that any medical expenses will be billed directly to me or my insurance company.
I have fully read the above waiver and I agree to it.
I hereby grant the James River Association the unconditional right to use me/my child’s name, voice, and photographic likeness of me/my child in connection with any of their audio video production, articles, website materials or press releases, but not as an endorsement.I DO NOT grant the James River Association the unconditional right to use me/my child’s name, voice, and photographic likeness of me/my child in connection with any of their audio video production, articles, website materials or press releases, but not as an endorsement.
Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
Click 'Next' to continue to the payment information.

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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