Tang Math Summer Camp - Consent Agreement, Health and Release Form
Name of Camper *
Your answer
CAMPER INFORMATION
Date of Birth *
MM
/
DD
/
YYYY
Entering Grade *
Week(s) Attending *
Required
School Name *
Your answer
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Emergency Contact (besides parent/guardian) *
Your answer
Phone Number *
Your answer
HEALTH INSURANCE
Health Insurance Provider *
Your answer
Phone Number *
Your answer
Policy Number *
Your answer
Policy Holder's Name *
Your answer
MEDICAL INFORMATION
Doctor's Name *
Your answer
Phone Number *
Your answer
Does camper have any food allergies or dietary restrictions? *
Is camper currently on any medication? *
Will camper be bringing medication to camp? *
Has camper had any past health problems that would affect his/her participation? *
Does camper have any communicable or transferable diseases or health conditions? *
Does camper have any psychological disorders (including ADHD)? *
If YES to any of the above, or if there is anything else we should know about, please explain:
Your answer
Medications used by Tang Math Camp
Check any medications that camper CAN take:
CONSENT AND RELEASE
I, parent/guardian of the above-named camper, give my permission for him/her to participate in Tang Math Camp. I understand and acknowledge that this program and associated activities involve certain inherent risks, which I accept. Risks may include, but are not limited to, injuries relating walking on sidewalks and crosswalks during field trips, using play structures at parks, and others similar. I've determined my child's health is adequate to participate safely in this program. In the event my child needs medical attention, I authorize and give consent for my child to be treated by emergency medical personnel. I understand that I am financially responsible for all medical charges incurred on behalf of my child and I authorize the health care insurance claims for my child. I hereby release Tang Math and all of their personnel, agents, affiliates, sub-contractors, staff and directors, from any and all liabilities to me with respect to injury, sickness, disease, loss or damage. This release applies to any and all liabilities to my child, whether arising from ordinary negligence or otherwise, and whether involving fees and expenses of any kind. In the event that some other person entity seeks compensation for these released liabilities, I or my estate will indemnify and hold harmless Tang Math for all sums reasonably incurred in response to that claim. This release is to be interpreted and enforced under state law. I also authorize Tang Math to use any photos taken during the camp program and comments made by campers and family members for marketing materials and other company publications. I acknowledge this to be voluntary and that no financial compensation will be given. By completing this form, you agree that the information provided on this sheet is complete and correct.
Parent/Guardian Release Confirmation *
I, the applicant for this form, acknowledge that I have read, understand, and accept the above terms and conditions, and warrant the truthfulness of the information provided in this application.
Electronic Signature *
Please type your full name below. By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your answer
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