Summer Camp Detailed Registration Form

Music and Math Camper Information

Camper's Name *

First Name Middle Name Last Name

Birth Date *

Month Day Year

Grade *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information (1)

Name *

First Name Last Name

Primary Phone Number *

Area Code Phone Number

E-mail

Parent/Guardian Information (2)

Name

First Name Last Name

Primary Phone Number

Area Code Phone Number

E-mail

Child Lives with

Please list the names of people who can pick up child other than parent/guardian:

Authorized

First Name Last Name

Authorized

First Name Last Name

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number

Area Code Phone Number

Medical Release Information

Policy Number

Name of Health Insurance Provider *

Primary Physician Name

First Name Last Name

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the camper prescribed an inhaler? If yes, please explain any instructions.

T-shirt order: *

How did you hear about Atlanta Children's Choir?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Atlanta Children's Choir during the selected camp. In exchange for the acceptance of said child’s candidacy by Atlanta Children's Choir, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Atlanta Children's Choir and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Atlanta Children's Choir. including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all recreational activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Atlanta Children's Choir. and its affiliates including Directors, Teachers, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Photo Release

I hereby give permission for my child to be photographed during the Atlanta Children's Choir: Music and Math 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 and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity wil not be disclosed, I do not expect compensation and that all photos are the property of the Atlanta Children's Choir and its affiliates.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Please complete donation payment information by clicking the Donate tab on website: http://www.atlantachildrenschoir.org/

Summer Camp Registration