Healthcare Hero Day Camp Registration Form

Healthcare Hero Day Camp Registration Form

Please provide your child's details and emergency contacts to complete the registration. Additionally, please send your child with a change of clothes because there will be a water balloon fight at the end of camp. *if weather permits.
Student Information
Camper's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade in School
ex. 6th, 7th, 8th
Student's T-Shirt Size (unisex)
Please list any allergies or dietary restrictions the student has. If none, please put N/A.
Parent/ Guardian Information
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Medical Permission (fill in the blanks)
In the event of an emergency, I authorize the Camp Instructors to seek emergency care for my child. My preferred hospital is Preferred Hospital . In the event of any accident or health problem which may require the attention of a physician, I may be contacted at (phone) Area Code Phone Number . If I am not available First Name Last Name may be contacted at Area Code Phone Number and is authorized to act on behalf of my child.
Marketing Release
I hereby consent to and authorize the following uses and reproductions by Pinckneyville Community Hospital (PCH), including the Family Medical Center, Area Health Education Center (AHEC), or anyone authorized by Pinckneyville Community Hospital, for any purpose, including but not limited to news releases, marketing, advertising, videos, fundraising, the hospital website, social media sites, and media interviews. I (student, job shadower, or volunteer) consent to Pinckneyville Community Hospital's use of photographs of me, with or without my name, for such purposes, including but not limited to publicity, illustration, advertising, web content, bulletin board, newsletter, and recognition programs. I understand I will not be compensated for this use. All negatives, together with the prints, videos and testimonials shall constitute the property of PCH, solely and completely. I understand that I may revoke this authorization in writing at any time by contacting the Marketing Director or Administrator/CEO of PCH at 5383 State Route 154 Pinckneyville, IL 62274, except to the extent that action has been taken in reliance on this authorization. Anyone under 18 years of age, authorization must be given by parent or guardian by signing below.
We often publish a photo of the class on the hospital social media page and the newspaper. Please note if you consent to the marketing release above:
Parent/ Guardian Signature
Should be Empty:

Healthcare Hero Day Camp Registration Form

Student Information

Parent/ Guardian Information

Emergency Medical Permission (fill in the blanks)

Marketing Release