Document ID: e1eb44f08225153a6c4b9116d2d3b6ef76bca515
March 10, 2016
Signed On : https://www.nwdanishcamp.com

Camper Registration eSig - Ellie Watts


HIMMELBJERGET DANISH CAMP

Ellie Watts          

BIRTHDATE: 05/27/2003

Parent / Emergency Contact info

Parent 

Non-parent emergency contact

Sean and Emily Watts

  • (360) 907-4081 (home)
  • (360) 907-4081 (work)
  • (360) 907-4081 (cell)

 

Sharon Watts 
Grandmother

  • (360) 953-0625 (cell)
  • (360) 953-0625 (other)

 

Camper Health Details

Medications: 

Date of last tetanus shot/booster:
 05/05/2010

 

Family Doctor: 
Evergreen Pediatrics
(360) 892-1637
Vancouver

Insurance provider: 
Regence Blue Cross
Phone: (877) 354-0484

ID number: AGR008A22119
Group number: 174097M1AA
Name of primary insured: Sean Watts

 

 

Allergies information: 

 

 

Payment Details

Tuition: –Please select–
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.
I agree

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

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.

Signed by Emily Watts
Signed on: May 16, 2018

Signature Certificate
Document name: Camper Registration eSig - Ellie Watts
Unique Document ID: e1eb44f08225153a6c4b9116d2d3b6ef76bca515
Emily Watts
Party ID: 9b2cc453-4784-4b36-ac2e-a8665c0aac3a
IP Address: 50.38.69.232
Security Level: E-mail ,
Digital Signature:
Emily Watts
Multi-Factor
Digital Fingerprint Checksum
0bcfe9b4f37b5d235eb1da9d31cda2ad
Timestamp Audit
2016-03-10 23:14:33 PDTCamper Registration eSig Uploaded by Maren Williams - williams.maren@gmail.com IP 50.38.69.232
2018-05-16 10:44:04 PDTDocument viewed by Ellie Watts - wattscounseling@gmail.com IP 50.38.69.232
2018-05-16 10:44:31 PDTSigner name Ellie Watts was changed to Emily Watts by wattscounseling@gmail.com IP: 50.38.69.232
2018-05-16 10:44:31 PDTDocument signed by Emily Watts - wattscounseling@gmail.com IP 50.38.69.232
2018-05-16 10:44:31 PDTThe document has been signed by all parties and is now closed.
2018-06-18 02:32:00 PDTDocument viewed by Emily Watts - wattscounseling@gmail.com IP 54.196.42.146