☰ MENU

medical release and waiver

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