Kids Camp Registration Form

Personal information

*Camp Location

*Participant's First Name:

*Participant's Last Name:

*Gender:

Male Female

*Date of Birth

*Age at Camp

*Completed Grade

*Address:

*City

*State:

*ZIP code:

Sibling Participant? If so, name:

Want siblings in same group?

*Primary Adult Contact Name

*Relationship

*Primary Adult Daytime Phone number:

*Primary Adult Cell Phone Number

*Secondary Adult Contact Name

*Relationship

*Secondary Adult Daytime Phone Number

*Secondary Adult Cell Phone Number

*In an emergency, if no parent/guardian is available

*Relationship

*Daytime Phone

*T-Shirt Size

*Images/videos of you child may be used for promotional purposes. By enrolling your child in camp, you authorize us permission to use these images/videos. You will not be paid for use of the images/videos. Do you authorize this usage?

*I understand that Labette Health and supporting agencies are not responsible for my child's belongings if they come up lost or missing.

MEDICAL AUTHORIZATION: I recognized that participation in recreation and instruction activities, even when well supervised and managed, poses a risk to my child and I agree to assume such risk on behalf of my child. I, the undersigned, hereby hold the Montgomery County EMS, Labette Health EMS, its employees and volunteers harmless from liability for any and all medical and/or accident expenses that my minor child may incur during their involvement in the Public Safety Kids Camp. The health history is correct so far as I know, and the person herein described has permission to engagee in all camp activities except as noted.

AUTHORIZATION FOR TREATMENT: By selecting yes, I hereby give permissoin to the medical personnel selected by Montgomery County or Labette Health EMS to provide emergency medical treatment; to administer over-the-counter and prescription medications as directed by a parent; to release any records necessary for insurance purposes; and to provide or arrange necessary related emergency transportation for my child. In an emergency or in the event I cannot be reached, I hereby give permission to the physician selected by Montgomery County or Labette Health EMS to secure and administer treatment, including hospitalization, for the person named above.

*This camper has the following chronic health concerns:

Recent injury, illness or infectious disease Convulsions, seizures or epilepsy Asthma Diabetes Ever been knocked unconscious or head injury Heart condition Vision, speech or hearing problems Bleeding/clotting disorders No chronic health concerns

Other health concerns

*Can your child swim independently?

*Does this camper have any mental, social or emotional health needs?

If yes, please explain

*Please list any allergies, medications or other necessary medical information. If you have no additional information, please type in N/A

*By typing my name in the following box, I verify that all information is correct and I agree to all terms of this registration form.

*Today's Date

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