Child

Child's name (first and last)

Child's Birth Date

Child's Address

Parent/Guardian - Contact Information

Parent/Guardian #1

Name (first and last)

Address

Email

Phone Number

Parent/Guardian #2

Name (first and last)

Address

Email

Phone

Medical Release Information

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical Problem(s)

Required treatment(s)

Should paramedics be called?

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

No

Yes, please explain

Is your child allergic to any food or medication?

No

Yes, please explain

Does your child require a special diet?

No

Yes, please explain

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Emergency Contact Information

Please list 3 emergency contacts to include their name, phone numbers, and relationship to camper

Please list all people in addition to parents/guardians who are permitted to pick up and/or drop off your child:

I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

I understand that Heeling House, Inc. will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Terms of Agreement

Payment and Cancellation

I understand that payment is due at the time of service and that final enrollment is contingent upon complete payment. There are no refunds for absences, changes, or withdrawals after camp starts.

Photo Release

I hereby give permission for my child to be photographed during Heeling House Summer Camp. I understand the photos and/or videos may be used for publications, promotions, advertising, and/or for other related endeavors for Heeling House, Inc.

Opt in to photo release

Opt out of photo release (pictures will be used for camp crafts only)

I understand that although my child’s photograph or video may be used for advertising, I do not expect compensation and that all photos are the property of Heeling House, Inc. and its affiliates.

Risk of Participation

I am willing to accept assumption of the risk of participation in camp activities and the risk of illness, bodily injury, or property damage while under the supervision of Heeling House in the Heeling House Center or a public space.

I acknowledge that my child is expected to follow the instructions of Heeling House instructors and abide by all rules established by them. Failure to follow the rules of Heeling House or its instructors may result in excusal without refund.

Acknowledgement of Informational Packet

I acknowledge that I have received and reviewed the Parent Informational Packet for Heeling House Junior Trainer Camp in full. I agree to all the terms and conditions listed in that informational packet and agree to abide by all rules and regulations as stated in the packet. If breach of rules or regulations occur, I acknowledge that my child may be removed from completing camp.

Heeling House, Inc. is not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's’ photos and quotes may be used for publicity purposes, unless opted out. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).

Signature

Junior Trainer Camp Registration

Child

Parent/Guardian - Contact Information

Medical Release Information

Emergency Contact Information

Terms of Agreement

CONTACT