CAMP PICASSO RELEASE AND MEDICAL AUTHORITY
In consideration of Ms. Bonnie Baker and Ms. Joane Farrell( counselors) allowing undersigned, on behalf of themselves and their child, release and forever discharge the counselors, insurers, employees and agents from and all liability for damages, either personal or property, arising from said child’s participation in al camp related activities and/or use of facilities of any foregoing entities.
In the event of a medical emergency or accident involving _________________ (camper name) it is understood that all attempts will be made to contact undersigned; however, the undersigned hereby grant permission to the counselor or camp personnel to seek any and all medical care necessary to treat emergency or accident, if the undersigned cannot be reached.
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NOTE BOTH PARENTS AND/OR ALL GUARDIANS MUST SIGN.
Guardian 1
Please print name:_______________________________________________
Email address: __________________________________________________
Address _______________________________________________________
Home Phone: _____________________Work phone:___________________
Cell phone: _______________________ Pager: _______________________
Guardian signature _____________________________ date: ____________
Guardian 2
Please print name:_______________________________________________
Email address: __________________________________________________
Address _______________________________________________________
Home Phone: _____________________Work phone:___________________
Cell phone: _______________________ Pager: _______________________
Guardian signature _____________________________ date: ____________
Camper signature:___________________________________ date: ___________
Emergency contact and #______________________________________________
Medical Insurance Company Name ______________________________________
Policy number ___________________________________
Pediatrician _________________________________ phone ___________________
Preferred hospital ________________________________
Allergies and/or health problems ___________________________________
Bee sting allergy? _____________________________________
In order to insure a safe and pleasurable camp experience, I will cheerfully participate in camp activities and follow all safety precautions and rules of Camp Picasso. I will treat counselors, fellow campers, art supplies and camp environment with safety and respect.
camper signature ____________________________________