2019 Summer Camp Form

Camper Information

Campers Name*

First NameLast Name

Birth Date

MonthDayYear

Age*

Gender

MaleFemalePrefer not to answerOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name*

First NameLast Name

Home Number

Area CodePhone Number

Cell Number*

Area CodePhone Number

E-mail*

Select Camp*

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

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

Is the child prescribed an inhaler or other medications? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by A Ton of Fun Theater during the selected camp. In exchange for the acceptance of said child’s candidacy by A Ton of Fun Theater. I assume all risk and hazards incidental to the conduct of unsanctioned activities, and release, absolve and hold harmless the above organization and IHCA (Indian Head Center for the Arts)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 due to unsanctioned activities, I hereby waive all claims against A Ton of Fun Theater or IHCA including all dirctors and affiliates, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

I understand that my child's likeness may be used in the form of pictures or film during normal camp performance activities such as rehearsals, performance, trainings, etc. His or her likeness may be used for future promotions or documentation of said camp without compensation for said images. Please select answer from box below.

Yes, I have read and understand the Informed consent information

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 A Ton of Fun Theater and its affiliates including Directors, aids, 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 season.

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.

Confirmation

BY ACKNOWLEDGING AND SELECTING I AGREE 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.

I agreeI do not agree

B.B.'s Kidventure Camp Registration 2019