2025 Camp Fury Registration
Date: October 25, 2025
Time: 8:00am - 4:00pm
Location: KCKFD Station 16 at 1900 S. 55th St, Kansas City, KS 66106

The information on this form is gathered to complete your girls registration and to assist us in identifying appropriate care for your daughter during Catching Fury. This should be completed by the girl's parent/guardian. Any changes to this form should be provided upon the participant’s arrival. Please provide complete information so that instructors and/or healthcare personnel can be aware of your daughter’s needs.

This form will take approximately 5-10 minutes to complete. Please note that your girls spot in Catching Fury is not secured until this completed form has been received.

Please provide an email where a copy of this completed form will be sent.
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Email *
First Name of Girl *
Last Name of Girl *
Girl's Preferred Name/Nickname *
Girl's Date of Birth *
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Girl's Age *
Name of School *
Participant must be currently in 7th, 8th or 9th grade. No exceptions will be made. *
Girl's T-shirt Size *
Primary Parent/Guardian Name (First, Last) *
Secondary Parent/Guardian Name (First, Last)
Primary Parent/Guardian Email that is checked frequently *
Secondary Parent/Guardian Email that is checked frequently
Primary Parent/Guardian Main Phone Number - We will use this number in case we need to get a hold of you during camp. *
Secondary Parent/Guardian Main Phone Number - We will use this number if we can't get a hold of the primary parent/guardian at the number above.
Girl's Home Address *
Name (First, Last) Emergency Contact (This cannot be the same individual as Primary Parent) *
Emergency Contact relation to girl (Aunt, Uncle, Friend of Family, etc) *
Primary Phone Number of Emergency Contact - this number will be used if parent/guardians can not be reached. *
Please explain any medical conditions that may affect your girl at Catching Fury. Put N/A if none. *
Check all that apply and explain in detail any checked answers.  *
Please explain, in detail, any checked boxes from above. Please put N/A if none was selected. *
Allergies: Please list ALL allergies, the type of reaction and its severity, treatment and date of last reaction. Include allergies to medications, food, insects, animals, plants, etc. Please put N/A if there are no allergies. *
Does the participant suffer from Anaphylaxis? *
Does your girl carry an epipen, inhaler or other medications?  *
Please explain in detail if you answered yes to the last question. Please put N/A if no was selected. *
Any other medical conditions (allergies, physical, mental or other) or restrictions Catching Fury should be aware of? Please put N/A if there are no other medical conditions. *
By selecting the "I Accept" box, you are signing this Health History Form  and release request electronically. You agree your electronic signature is the equivalent of your manual signature. Your signature (hereafter referred to as “Signature"), implies acceptance and agreement as if actually signed by you in writing.
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Required
This health history is correct and complete as far as I know. I hereby permit the agencies and instructors of Catching Fury to provide, seek, and consent to routine health care, administration of prescribed medications and emergency treatment for my child, as may be necessary, including, but not limited to x-rays, routine tests and treatment, and/or hospitalization. I also permit the agencies of Catching Fury to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. 
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Required
I intend that the instructors be treated as acting in loco parentis if the person herein named is a minor. Further, I intend that the appropriate representatives of the agencies of Catching Fury be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510 (b)) to the disclosure to camp representatives of the protected health information of the person herein described as necessary: (i) to provide relevant information to the Camp Fury representatives related to the person’s ability to participate in activities; and (ii) in the case of minors, to provide relevant information to the Camp Fury representatives to keep me informed of my child’s health status. I authorize any hospital, physician, medical practitioner, clinic, or other related facility to furnish to Mutual of Omaha Insurance Company, or anyone acting on its behalf, all information concerning medical, dental and hospital records for my child, to be used for the purpose of evaluating claims for benefits. I have the right to receive a copy of this authorization upon request.
 *
Required
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Catching Fury agencies to secure and administer treatment, including hospitalization and/or injection and/or anesthesia and/or surgery for the person named above. *
Required

My girl is in good physical condition and has not had any serious illness or operation since her last health examination. If my girl should have a serious illness, operation or be exposed to a contagious disease between the date the permission form is signed and the activity, I will notify Catching Fury.

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Required

Catching Fury will include mild physical activity potentially including the following: completing an obstacle course, climbing stairs, lifting light weights. To the best of my understanding, my girl will not have any problems with the physical requirements of Catching Fury.

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Required

If you stated above, that your girl may have issues with some physical requirements, please provide an explanation in detail. Please put N/A if your girl will have no issues.

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We take pride in all of our endeavors, including the use of communication tools that help keep family and friends informed about events and opportunities that take place. We photograph and video events and some of those photographs and videos may contain images of the girls, instructors and invited guests participating. We will be posting and/or printing images of Catching Fury that may contain images of your girl. In addition, media, both print and television, may be taking video of Catching Fury that may contain images of your girl.

I understand that my girl will be photographed and/or videoed as part of this program.

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Required
Name (First, Last) of Parent/Guarding completing this form and signing this agreement. *

Race/Ethnicity of Catching Fury participant. Please check one. Answers are only used for reporting purposes.

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Is there anything additionally you would like to add regarding the participation of your girl in Catching Fury.

A copy of your responses will be emailed to the address you provided.
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