Camp Imagination (Going into 1st-5th)
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TimestampChild's First NameChild's Last NameChild's Date of BirthAdressCityZip CodeGuardian NameGuardian Primary Phone NumberGuardian Secondary NumberEmergency Contact Name and NumberEmergency Contact NumberYour Email AddressSecondary EmailChild's SchoolDates Your Child is AttendingI,a parent of guardian ofa minor, do hereby consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital service that may be rendered to said minor under the general or specific instructions of any physician or at a licensed hospital. I hereby authorize any hospital, physician, or other person who has attended or examined the minor to furnish the camp’s insurance company, or its representative, any and all information with respect to any illness, medical history, and/or consultation. I also give consent for the above named minor to participate in the activities of the Camp Imagination summer day camp program. This consent shall remain in continuous effect until revoked in writing or until said minor is removed by parent/guardian from the care of one or more of these opportunities. A photostatic copy of this authorization shall be considered as effective and valid as the original. I hereby grant to Restoration Community, Inc., emPowered Kids, permission publish and re-publish photographic portraits or pictures of minor for promotional purposes. I hereby warrant that I am of full age and have every right to contract for the minor in the above regard. I state further that I have read the above authorization, release, and agreement, prior to its execution, and that I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. I/We also give permission for said minor to travel to and from program activities on the transportation provided by emPowered Kids. This would include, but not be limited to bus, van or public conveyance. I am also responsible for picking up my child at the designated drop-off zones at the established times. It is the guardians’ responsibility to update emPowered Kids with change of phone numbers in order for effective communication to occur or in case of emergencies. Enter your name to agree to the terms: The name(s) below CANNOT, under any circumstance, pick up my child.I give my child permission to walk home or find a ride at their discretionDoes your child have ANY special needs (mental or physical) that we should know about? (Convulsive disorders, diabetes, allergies, behavioral disorders, wandering etc.)Preferred PhysicianPhysician's PhoneInsurance Policy NumberInsurance ProviderChoose how many weeks you're paying forWhere are we picking up and dropping off your child?Would you like to pay by the week?How are you going to pay?
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