Clark County Sheriff's Office Hero's Camp
Event Timing: 2nd and 3rd Grade Grade: June 13, 2017 | 4th - 6th Grade: June 14, 2017 | 7th Grade: June 25th, 2017 | Contact us at (812) 283-4471 ext. 3152 or jjawor@clarkcosheriff.com
Hero's First Name
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Hero's Middle Initial
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Hero's Date of Birth
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Hero's Last Name
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Hero's Grade (in the upcoming school year)
Hero's Address
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Hero's City
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Hero's Zip Code
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Hero's Phone Number
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Hero's Emergency Contact Person
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Emergency Contact Person's Relationship to Hero
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Emergency Contact Person's Phone Number
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Emergency Contact Person's Email
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Hero's T-Shirt Size
Any Medical Issues of Hero?
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Any Medications Taken by Hero?
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Does the Hero Have Any Allergies?
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I/we, as parents/guardians of the above listed Hero give permission for the 2016 Clark County Sheriff's Office Hero's Camp nurse or medical staff to give my child medication as listed and instructed above pursuant to Indiana Code IC:16-36-1. Should my/our child need medication during the time they are at participating in the 2016 Clark County Sheriff's Office Hero's Camp, I/we will send the proper medication with them in the original prescription bottle labeled with his/her name. I/we acknowledge and agree to this section with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
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I/we, as parents/guardians of the above listed Hero understand that transportation to and from the 2016 Clark County Sheriff's Office Hero's Camp is my responsibility. I/we acknowledge and agree to this section with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
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I/we, as parents/guardians of the above listed Hero understand that the following items are not allowed and expressly prohibited at the 2016 Clark County Sheriff's Office Hero's Camp: cell phones, pagers, iPods, iPads, MP3 Players, CD/DVD/BluRay Players, handheld video games, laptops. Failure to abide by this rule can result in the Hero being asked to leave the Camp. I/we acknowledge and agree to this section with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
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I/we, as parents/guardians of the above listed Hero give express permission to the Clark County Sheriff's Office to use my/our child's likeness in any Hero Camp promotional publications, social media posts, and news articles. I/we acknowledge and agree to this section with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
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I/we, as parents/guardians of the above listed Hero give express permission to the Clark County Sheriff's Office to exercise their best judgement, based on the recommendation of an attending physician, to authorize EMERGENCY TREATMENT or SURGERY for my/our child should they sustain a serious injury or illness and I/we are unable to be reached. I/we acknowledge and agree to this section with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
Your answer
I/we, as parents/guardians of the above listed Hero do hereby release the Clark county Sheriff's Office, New Chapel EMS, Utica Fire Department, and any other sponsors, their agents, and employees from all actions, damages, claims, or demands which I/we, my/our heirs, executors, administrators, or assigns may have against the above named agencies for all personal injuries known or unknown and injuries to property real or personal, caused by, or arising out of, the above described activities and/or participation. I/we, the parent(s)/guardian(s) of the aforementioned Hero, acknowledge and agree to this release and understand its terms. I/we execute it voluntarily and full knowledge of its significance, pursuant to Indiana Code IC:16-36-1, with my/our electronic signature [INSERT YOUR FULL NAME AND RELATION TO HERO IN SPACE PROVIDED ex. John William Smith, Father].
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