Health and Wellness
This health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why the applicant should not participate in the prescribed activities as noted. If this information changes during the year, I will notify the Camp Ignite administrators in writing. I understand that this information will remain confidential to Camp Ignite staff, a designated person trained in first aid, or emergency personnel as needed. I hereby give permission to the Atlanta Fire Rescue Department to provide routine health care, administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the adult in charge to arrange necessary related transportation for my child.
Emergency Contact Information
Person to notify in an emergency (other than parent/guardian).
Camp Ignite requires a copy of the participant's current health insurance or Medicaid card.
Please make a copy of the front and back of the card:
We will work with campers who do not have health insurance; just let us know the information requested below.
Additional Required Information
I hereby give permission for named participant to be transported during Camp Ignite program dates. Please type parent/guardian initials in selected box.
I hereby grant the Atlanta Fire Rescue Department and all the organizations/partnerships associated with Camp Ignite permission to record my child/ward's or my (if adult participant) likeness and/or voice for use in television, films, radio or printed media to further the aims of the Camp Ignite Program in related campaigns and magazines articles, booklets, posters and in any other ways they may see fit.
In the event I cannot be reached in an emergency, I hereby give permission to employees of the Atlanta Fire Rescue Department and all the organizations/partnerships associated with the Camp Ignite program to secure proper medical care for my child as deemed necessary. This permission extends from minor first aid treatment to, under a doctor's orders, hospitalization, injections, anesthesia, surgery and other medical procedures deemed necessary.
The undersigned hereby releases and holds harmless the Camp Ignite Program, City of Atlanta, its Mayor and Council and any officers, employees or agents thereof, including without limitation the Atlanta Fire Rescue Department, from any and all claims, liabilities, or demands whatsoever arising or claimed to have arisen out of the enrollment or participation in any program by the participant herein.