Summer Camps Emergency Info and Releases

Wild Roots Summer Camps 2017
Emergency Info and Releases

Please fill out this information for your child to participate in summer camp and submit it at least 2 weeks prior to your child's first session of summer camp. Please fill out separately for each child attending. If you are a late registrant, please submit the info here - and you may also have to fill out hardcopies on the first morning of camp. If you have questions, contact Kolmi at [email protected].

* Indicates required field

Child's Name *

First

Last

Child's Date of Birth (Month/Day/Year) MM/DD/YYYY *

Emergency Contacts

Parent/Guardian Contacts. Please list full names, best daytime phone numbers, any additional phone numbers, including area code. *

Additional Emergency Contacts.. Please list full name, relationship, and all applicable phone numbers including area code. *

Media Release

I agree that portions of the program may be recorded or photographed for the purpose of documentation and promotion. They may be used for these purposes only.* *

Yes No

Acceptance of Risk

Acceptance of Risk: I understand that outdoor activities, such as those at a nature-based program, naturally contain risk. In consideration of the benefits to be derived from participation in such activities, I choose for my child to participate. I release from liability and waive my right to sue Wild Roots, their employees and volunteers.* *

Health Info

If your child has any allergies or health issues that should be known in an emergency, please provide info below. *

Emergency Medical Release

In case of emergency, I hereby give consent to Wild Roots staff to obtain emergency medical care prescribed by duly licensed physician or emergency personnel for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the child named below.* Please post your child's full name below. *

Signature

Parent Signature (please type your name) *

Date of Signature: Month/Day/Year MM/DD/YYYY *

Thank you, please be sure to click Submit below!

Submit