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Camper Name (first and last): _____________________________ Nickname: ___________ Age: ________

Birthday: (month/day/year): ____________

ď ˛ Boy

ď ˛ Girl

Parent/Guardian Names: __________________________________________________________ Address: ___________________________________________________________________ City: _________________________ State: ________________ Zip Code: __________________ Home Phone: _________________________

Alternative Phone: _______________________

Work Phone: __________________________

Place of Work: __________________________

Persons, other than the above, authorized to pick up the camper: Name: __________________________________ Relationship:_______________ Name: __________________________________ Relationship: ______________ Only a parent, legal guardian, or other authorized person with PHOTO ID can sign the camper out for release from our care. Emergency contacts: Name: ____________________________

Relationship: ____________________

Home Phone: _____________________

Alternative Phone: ___________________

Name: ____________________________

Relationship: ____________________

Home Phone: _____________________

Alternative Phone: ___________________


Camper Medical Information Health Insurance Provider _____________________ Policy number: ______________________ City and State ______________________________

Phone______________________

Physician’s name ______________________________

Phone ______________________

Dentist/Orthodontist name ______________________

Phone _______________________

Does camper have any of the following conditions (check all that apply)?  Asthma  Allergies (general)  Bee sting allergy  Poison oak allergy  Car/motion sickness  Bowel/bladder problems  Epilepsy/convulsions  Hay fever  Heart trouble/murmur  Headaches

Backaches/weak back

 Respiratory problems  Sinus Trouble  Sleep Walking  Bed Wetting  Frequent ear infections  Diabetes  Blood/clotting disorders  Fainting/dizzy spells  Nosebleeds  Hypertension  Other (Please explain) ______________________________________________ Does camper have any food or drug allergies or special dietary requirements? Yes/No If yes, please explain:_______________________________________________________________ _________________________________________________________________________________ Mark the month and year the camper had the following immunizations: Tetanus __________ Measles __________ Has camper ever had any serious injuries or operations? Yes/No If yes, please explain:_______________________________________________________________ _________________________________________________________________________________ Has camper ever required psychiatric counseling or hospitalization? Yes/No If yes, please explain:_______________________________________________________________ _________________________________________________________________________________ Is camper required to take any medications? Yes/No If yes, please explain (Medication, Name, Reason Dosage, Taken, When, etc): _______________________________ _________________________________________________________________________________ Is camper capable of participating in strenuous activities? Yes/No If yes, please explain:_______________________________________________________________ _________________________________________________________________________________ Please indicate camper’s swimming ability: ______________________________ Does the camper have any strong likes or dislikes (food, activities, etc.) that his or her program counselor should be aware of? If yes, please explain: _________________________________________________________________________________ _________________________________________________________________________________


The Salvation Army Kroc Adventures Day Camp Multi-jurisdictional Authorization and Release for Medical and Dental Treatment The undersigned, as the parent or parents, or legal guardian or legal guardians, of __________________,a minor (the “minor”), hereby authorize The Salvation Army Kroc Adventures Day Camp and its authorized directors and leaders (collectively The Salvation Army) to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care (collectively “medical care”) to be rendered to the minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the laws of the state or other jurisdiction in which medical care is sought, and to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered to the minor by a dentist licensed under the laws of the state or other jurisdiction in which dental care is sought. It is understood that if time and circumstances reasonably permit, The Salvation Army will endeavor, but is not required, to communicate with at least one of the undersigned prior to the rendering of medical care or dental care for which consent is given pursuant to this authorization. The undersigned understand and agree that The Salvation Army shall not be legally or financially liable for any claim arising from any medical care or dental care provided pursuant to this authorization. The undersigned hereby agree to indemnify and to hold The Salvation Army harmless from any claim made by or on behalf of said minor arising out of any medical care or dental care provided pursuant to this authorization. This authorization is given to The Salvation Army for use in conjunction with any event operated by The Salvation Army, and shall be valid until revoked in writing by the undersigned or any of them. SIGNED: ___________________________________________DATE __________ SIGNED: __________________________________________ DATE __________ MEDICAL INSURANCE COMPANY: ________________________________________________ POLICY NUMBER: _______________________________

EXPIRES: _________________

NOTE: The Salvation Army requests that, if the minor is in the custody of both parents or more than one legal guardian, both or all sign this authorization. The Salvation Army understands that the minor is in the custody only of the person or persons who have signed this authorization. * If for religious reasons you cannot sign this, The Salvation Army should be contacted for a legal waiver which must be signed for attendance.


THE SALVATION ARMY KROC ADVENTURES DAY CAMP RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT IN CONSIDERATION of being permitted to utilize the facilities, services and programs of THE SALVATION ARMY (or for my children to so participate) for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with The Salvation Army, the undersigned for himself or herself and such participating children and any personal representatives, heirs and next of kin, hereby acknowledges, agrees and represents that he or she has inspected, or immediately upon entering or participating will inspect and carefully consider such premises and facilities of the affiliated program. It is further warranted that such entry into The Salvation Army for observation or use of any facilities or equipment or participation in such affiliated program constitutes an acknowledgment that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered ant that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation by the undersigned and such children. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE SALVATION ARMY FOR ANY PURPOSE INCLUDING, BUT NOT LIMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY OFF-SITE PROGRAM AFFILITIED WITH THE SALVATION ARMY, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: 1. THE UNDERSIGNED, ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENENTS NOT TO SUE THE SALVATION ARMY, its directors, officers, employees, and agents (hereinafter referred to as “releases”) from all liability to the undersigned or such children and all his or her personal representatives, assignees, heirs and next of kin for any loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned or such children whether caused by the negligence of the releases or otherwise while the undersigned or such children are in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with THE SALVATION ARMY. 2. THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releases and each of them from any loss, liability, damage or cost they may incur due to the presence of the undersigned or such children in, upon or about THE SALVATION ARMY or participating in any program affiliated with THE SALVATION ARMY whether caused by the negligence of the releases or otherwise. 3. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE OR THEFT to the undersigned or such children due to the negligence of the releases or otherwise while in, upon or about the premises of THE SALVATION ARMY and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with THE SALVATION ARMY. THE UNDERSIGNED further expressly agrees that the foregoing RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the law of the State of Michigan and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THIS RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT and further agrees that no oral representations, statements or inducement apart from the foregoing written agreement have been made. 4. The undersigned hereby irrevocably grant to The Salvation Army the absolute right and permission to copyright and/or publish or use photographic portraits or pictures of me or my child or in which we may be included in whole or in part, or composite or distorted in character or form, in conjunction with my name or a fictitious name, or reproductions thereof in color or otherwise, made through any media, for art, advertising, or any other lawful purpose whatsoever. I also grant The Salvation Army the same right and permission to use any statements or testimonials made by me. 5. The undersigned hereby irrevocably grant to The Salvation Army the absolute right and permission to transport my child on field trips described in the Kroc Summer Adventure Day Camp schedule for the summer of 2010. 6. The undersigned understands and acknowledges that The Salvation Army Kroc Adventure Day Camp is a Christian Camp that will be teaching Bible principles through various techniques. Some of these techniques will include but not be limited to: discussion, dance, song, crafts, physical activities and activity sheets. I, ____________________________________ (Print Name) HAVE READ AND AGREE TO THIS RELEASE. Signature of Applicant/Parent __________________________________________________ Date: ________________________

2010 DAY CAMP MEDICAL FORM  

Parent/Guardian Names: __________________________________________________________ Home Phone: _____________________ Alternative Phone: _____...

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