Camper Registration eSig


HIMMELBJERGET DANISH CAMP 2016

          

BIRTHDATE: 

Parent / Emergency Contact info

Parent 

Non-parent emergency contact

  • (home)
  • (work)
  • (cell)

 

 

  • (cell)
  • (other)

 

Camper Health Details

Medications: 

Date of last tetanus shot/booster:
 

 

Family Doctor: 

Insurance provider: 

Phone: 

ID number:
Group number:
Name of primary insured: 

 

 

Allergies information: 

 

 

Payment Details

Tuition:
Extras:
TOTAL: 

 

 

PLEASE SIGN BELOW TO ACKNOWLEDGE AND ACCEPT THE FOLLOWING

Photography
I grant the right to photograph my child and use the photo reproduction of his/her physical likeness for publication processes, whether electronic, print, digital or electronic publishing via the internet.

Non-prescription pain relief
I grant the right for Staff to give my child non-prescription pain reliever, if needed.

Release of liability
I release Himmelbjgert Camp and Northwest Danish Association of any and all liability if my child is injured, falls ill or is disabled during the course of camp.

Medical/Surgical Release
I understand that every effort will be made to contact me if my child needs emergency medical/surgical treatment, but if it is impractical to do so, I HEREBY GIVE MY PERMISSION to the physician selected by camp staff to secure proper treatment, to hospitalize, or order injection, anesthesia, X-rays, or surgery for my child as named above.

Leave this empty:

Northwest Danish Camp http://www.nwdanishcamp.com
Signature Certificate
Document name: Camper Registration eSig
Unique Document ID: bbcee40f6e250877ba964a8408c89738064145e4
Timestamp Audit
2016-03-10 23:14:33 PSTCamper Registration eSig Uploaded by Cassy Johnson-Hodge - cassyjh@gmail.com IP 174.25.33.216