AHA! and Camp AHA!
(after hours activities
at NCES), a Town of North Canaan program
Contact and Medical Release
Form
Name: _____________________________ Phone:
_____________ E-mail: _________________
Age: _______ Grade
(in September): ____ Birth date:
____/_____/_____
Address: ____________________________ City: _____________________ State/zip: __________
Emergency contacts:
Parent Name: ____________________________________ Daytime phone: __________________
Parent Name: ____________________________________ Daytime phone: __________________
Other Name: _____________________________________ Daytime phone: __________________
Physician: _______________________________________ Phone: ________________________
Please list anyone besides your emergency contacts who may pick up
your child.
Name: __________________________________________ Phone: ________________________
Please list any medical concerns, such as allergies, medications, and/or medical history that your child may have. __________________________________________________________________
Can we give your child something for pain, if needed? Yes No What? _______________
Waiver
and Release of all Claims
Please
read this form carefully. When you
sign this form you waive and release all claims for injuries your child might
sustain arising out of their presence at or use of the facilities and/or
participation in the programs and/or activities of the Town of North Canaan’s
Camp AHA!
Acknowledge
risk injury: As a
participant in the activities or programs at Camp AHA!, I recognize and
acknowledge that there are certain risks of physical injury and I agree to
assume the full risk of any injuries, including death, damages or loss which my
child may sustain as a result of participation or use of such facilities,
activities or programs.
Waive,
Release & Indemnify: I
hereby waive, release and discharge any and all claims I may have or may
acquire against the Town of North Canaan and Camp AHA! and their officers,
agents, employees, and/or volunteers as a result of my child's participation in
activities and programs of Camp AHA!, except for willful and wanton misconduct
by Camp AHA! or its authorized personnel.
I have
read and fully understand the above Waiver and Release of all Claims Form.
_________________________________________ Date: _____________
printed
name of Participant(s)
__________________________________________ Date:
_____________
signature of Parent/Legal Guardian
Signature
below authorizes Camp AHA! to transport your child to field trips and secure
emergency medical transportation for your child. This form does not authorize
or guarantee treatment upon arrival at the designated source of emergency
medical or dental treatment, as each emergency facility sets their own
treatment procedures. Please sign below if you grant Camp AHA! permission to
transport your child for field trips and emergency care.
__________________________________________ Date:
_____________
parent's
signature
Fax: 860-824-0445 Phone: 860-824-0393
Mailing:
Lynn Nania 35 Undermountain Road Falls Village, CT 06031