Camp Redwood 2019 Medical Information and Permission and Releases

Child's Name *

Grades Anticipated Grade for the 2019-2020 School Year *

Parent/Guardian 1 *

Parent/Guardian 1 Email *

Parent/Guardian 1 Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 1 Phone Number *

Parent/Guardian 2

Parent/Guardian 2 Email

Parent/Guardian 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 2 Phone Number

Who will pick up your child from camp?

Please fill out the names and relationship with your child for each authorized person for camp pickup.

First and Last Name *

Relationship to Child *

First and Last Name

Relationship to Child

First and Last Name

Relationship to Child

Medical Information

Does your child have any allergies? *

Please Describe in Detail

Does your child take medication regularly? *

Please Describe in Detail

Note: If your child needs to take medication during the camp day, you will need to come to the office to pick up and fill out a permission to administer form.

Does your child have any medical condition or concern that the school needs to know about or that may impact their full participation in camp activities? *

Please Describe in Detail

Note: If your child needs to take medication during the camp day, you will need to come to the office to pick up and fill out a permission to administer form.

Emergency Contact Information

Three emergency contacts are required. One contact (minimum) must be different than the listed parents/guardians.

Emergency Contact 1 Name *

First

Last

Emergency Contact 1 Phone *

Emergency Contact 2 Name *

First

Last

Emergency Contact 2 Phone *

Emergency Contact 3 Name *

First

Last

Emergency Contact 3 Phone *

Preferred Physician *

Preferred Dentist *

Preferred Hospital *

Insurance Carrier *

Policy Holder *

Policy ID Number *

Permission and Release Form

I hereby grant permission for my child to use all of the play equipment and participate in all activities of the camp. *

I Agree
I Do Not Agree

I hereby grant permission for my child to leave the school premises under the supervision of a Redwood faculty and/or staff member for neighborhood walks and walking field trips. *

I Agree
I Do Not Agree

I hereby grant permission for the name and/or likeness of my child to be included in communication and marketing initiatives of the school. Internal and external marketing initiatives may include but are not limited to promotional literature published by Redwood Cooperative School, articles and/or photographs to be published in area newspapers and magazines, photographs and video featured on the Redwood Cooperative School website and on Redwood Cooperative School social media sites, and filmed segments to be aired on local television stations. *

I Agree
I Do Not Agree

I hereby grant permission for the Director or authorized school personnel to take any steps necessary to obtain emergency medical care for my child, if warranted. These steps may include but are not limited to attempting to contact a parent, guardian, the child's physician or any of the persons listed on the emergency contact information provided to the school by the child's guardian. If the above mentioned cannot be contacted, school personnel may do any of all of the following: call another physician, call an ambulance, have the child taken to an emergency hospital in the company of a staff member. In the case of emergency, a physician and/or emergency and medical professionals may examine the child and administer such emergency medical treatment as deemed necessary. Without such permission, the school assumes no responsibility to medical attention. Any expense incurred while enlisting the help of a medical personnel as listed above will be borne by the child's family. *

I Agree
I Do Not Agree

In consideration of Redwood Cooperative School permitting my child to engage in extracurricular activities and/or athletic events, I hereby voluntarily assume the risk of accident, injury or damage to person or property. Furthermore, I voluntarily release and discharge Redwood Cooperative School, its employees, agents, representatives, coaches and volunteers from, without limitation, any and all actions, causes of action, claims, or suits relating to my participation in such activity. *

I Agree
I Do Not Agree

Redwood Cooperative School

Camp Redwood 2019 Medical Information and Permission and Releases

Who will pick up your child from camp?

Medical Information

Emergency Contact Information

Permission and Release Form

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