REGISTRATION FORM - B

Emergency Medical Information

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Applicant’s Name (Last) (First) _______________________________________________________

Physician’s Name Telephone _______________________________________________________

Please list any special conditions (medications, disabilities, allergies, etc.)

Local Emergency Contact (non-parent)

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Name (Last) (First) _______________________________________________________

I agree and release and discharge Cannon School (the School) and its officers, directors, and agents and its partner organizations (and their officers, directors, and agents) of and from any claims, demands, or liability of damage arising from the participation of my child in any classes or programs of Camp Cannon. In the event that my child needs medical attention, I authorize the School and give my consent to the School to provide such service and/or to transport my child to a hospital or treatment facility. I hereby certify that my child is in good health and may participate in all activities, as noted in camp descriptions. I hereby give my child permission to ride in school-approved transportation to and from camp activities, as noted in camp descriptions. I hereby grant permission for images of my child to be included in Camp Cannon print, online, or social media marketing materials.

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Parent/Guardian Name (Print) _______________________________________________________

Parent/Guardian Signature Date