Solicitation Form

Participant Name

First NameLast Name

Birth Date

MonthDayYear

Class Completed

Camper's School

Email For Camp Information

Parent/Guardian Name

First NameLast Name

Who is authorized to drop & pick up child?

Authorized Pick Up Name

First NameLast Name

Authorized Pick Up Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Authorized Pick Up Phone Number

Area CodePhone Number

Relationship to child

I agree

Treatment/ Emergency care – I hereby give permission to the emergency care physician and/or Raiz Camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event, I cannot be reached in an emergency I hereby give permission to the physician selected by the Raiz Camp supervisor to secure and administer treatment, including hospitalization, for the person named above.

I agree

Informed Consent - I understand that camp activities can sometime have inherent risks and I hereby assume all risks and hazards incident to my family’s participation in Raiz Camp activities. I further waive, release, absolve, indemnify and agree to hold harmless the Raiz Camp, the organizers, volunteers, supervisors, officers, directors, participants, coaches, referees, as well as, persons or parents transporting participants to and from activities from any claims or injury sustained during my child participation in the summerprogram.I certify that my child is in good health and is amiable to normal discipline necessary for a successful group experience. I also understand that the deposits are non-refundable and will hold my child’s spot until the balance is due. Registration is not guaranteed until the balance is paid two weeks before the first day of the summer session. Failure to pay the balance, when due, could result in cancellation of my registration. I also understand if I do not give proper notification, all money paid will not be refunded for the summer program. We agree to honor the behavior policies of the Raiz day/sleep camps and understand that it is at the discretion of the camp director to suspend or dismiss campers from the program due to inappropriate behavior.

Parent / Guardian Name

First NameLast Name

Date

Raiz Summer Camp

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Releases and Authorizations