Registration Form Child's Name * First Name Last Name Nickname: Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Name: First Name Last Name Phone * (###) ### #### How will your child be getting too and from camp? Parent/Guardian Drop off Walking independently Carpool with other family Emergency Contact #1 First Name Last Name Phone (###) ### #### Emergency Contact #2 Phone (###) ### #### Additional Pickup persons Emergency contacts will be considered authorized to pick up your child with your permission or in case of an emergency when you cannot be reached. If there are any other details about emergency contacts or other individuals who may pick up your child please note those here. Child's Health Information Child's Healthcare Provider (Office Name) Pediatrician's Name First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Does your child have any allergies (incld. drug reactions) Does your child take regular medications? Yes No Other health concerns, including special health issues? Medical Insurance Coverage Insurance Company Name: Member Policy Number Policy Holders Name Employer Name: Consent to Medical Care and Treatment of Minor Children Consent to Treat * Please type your name below to indicate your authorization for staff of Adventure Wings Play Camp, certified in CPR/First Aid to render treatment to your child in the case of a minor injury in which emergency services does not need to bed contacted or until emergency services arrive. First Name Last Name In case of emergent need to transport If an emergent need arises and your child needs to be taken by medical professionals do you have a preferred location for treatment if possible? Permission to Transport in Case of Emergency By typing your full name below you agree to authorize and consent to emergent medical, surgical, and/or hospital care, treatment and procedures to be performed for your child by a licensed physician, health care provider, hospital or aid car attendant in the event you cannot be reached and it is deemed necessary or advisable by the physician or aid car attendant to safeguard your child's health. You waive your right of informed consent to such treatment and give permission for your child to be transported by ambulance or aid care to an emergency center for treatment. First Name Last Name Digital Signature By typing your name below you certify under penalty of perjury under the laws of the State of Washington that the information contained in this registration form is true and correct First Name Last Name Thank you!
