Children'S Chorus Of Maryland & School Of Music Day Camp Health Form Page 2

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AUTHORIZATION FOR PICK UP:
PAGE 2 of 2
List adults (other than parents) who are authorized and have agreed to pick up your child from camp. DO NOT LIST Parents in this
section. Adults listed will be asked for proof of identification when picking up your child.
1. ____________________________________________________________________ Phone _____________________________
Relationship to child _____________________________________________________Cell Phone__________________________
2. ____________________________________________________________________ Phone _____________________________
Relationship to child _____________________________________________________ Cell Phone _________________________
3. _____________________________________________________________________ Phone ____________________________
Relationship to child ______________________________________________________ Cell Phone ________________________
MEDICAL AND PERSONAL INFORMATION
: It is important that we are informed of any health problems or condi-
tions that may effect your child’s time at our
camp. IMPORTANT DISCLAIMER: The location where this camp is held, Maryland Pres-
byterian Church, keeps a colony of bees outside on the church
grounds.
If your child is allergic to bees and cannot be outside
where bees maybe present, they should not attend this camp.
ALL information is confidential.
Is your child allergic to bees? _______________________ Does your child have any other allergies?______________________
________________________________________________________________________________________________________
If so, what kind of reaction does your child have?_______________________________________________________________
________________________________________________________________________________________________________
List all other important medical Information, medication, any physical limitations, etc.:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Personal Information: Please list any other important information that camp staff should know about your child.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Family Doctor: _______________________________________ Phone_______________________________________________
Health Insurance: _________________________Company ID Number Group Number: _________________________________
PLEASE READ AND SIGN BELOW
As parent/guardian of the above child I hereby waive, release and forever discharge Children’s Chorus of Maryland & School of
Music and its representatives, camp staffers and all others acting on their behalf from any and all responsibilities or liability for
injuries or damage arising out of his/her presence on the premises and outdoor grounds of the Maryland Presbyterian Church. I
also hereby release all of those mentioned above and any others acting upon their behalf from any responsibility or liability for
any injury or damage sustained resulting from the participant’s use of the Maryland Presbyterian Church’s or Children Chorus of
Maryland & School of Music ‘s equipment or facilities. I understand the risks and dangers involved in participation in this camp
program.
I give permission for my child to be photographed while participating in Children’s Chorus of Maryland & School of Music (CCM)
camp, programs or activities and give permission for those photographs to be used for promotion of CCM’s programs.
Parent Signature _____________________________________________________________________ Date _________________
Parent Printed Name _______________________________________________________________________________________

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