Waiver Of Liability Emergency Care And Media Release Form

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WAIVER OF LIABILITY
EMERGENCY CARE AND MEDIA RELEASE FORM
CHILD’S NAME _____________________________________________________________
Address: ___________________________________________Phone: _________________
City: _________________________ State: ___________________________ Zip__________
Allergies, Special Needs, Medications taken regularly: ________________________________
EMERGENCY CONTACTS
Parent Name: __________________________Employer:_____________________________
Address: ____________________________________________________________________
Phone # 1:____________________Phone #2:________________Phone #3:_______________
Parent Name: __________________________Employer:_____________________________
Address: ____________________________________________________________________
Phone # 1:____________________Phone #2:________________Phone #3:_______________
IN THE EVENT PARENTS CAN NOT BE REACHED PLEASE CONTACT:
Contact #1: __________________________Phone: _____________________________
Contact #2: __________________________Phone: _____________________________
Physician Name: ________________________________________ Phone: _______________
Insurance Company Name_____________________________________________________
Policy Holder Name: _________________________________ Policy Number_____________
DISMISSAL AUTHORIZATION: Every day at dismissal time the Parent/Guardian or Authorized Alternate
must sign the child out. No child will be permitted to leave camp with persons other than those listed
below: (for camp use only)
Parent/ Guardian #1________________________Parent/Guardian #2____________________________
Alternate #1______________________________Alternate #2___________________________________

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