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medical release and emergency form

AHA! and Camp AHA!

 (after hours activities at NCES)

a Town of North Canaan program

Contact and Medical Release Form

Child’s name: _______________________________________ Age: ______     

Grade (in Sept.): _______   Birth date: ____/_____/_____

Address: _________________________________________________________

City: __________________________________ State: ______ Zip: _________

Emergency Contacts :

Parent Name: _______________________ Daytime Phone: _______________

Parent Name: _______________________ Daytime Phone: _______________

Other Name: ________________________ Daytime Phone: _______________

Email address: _______________________,  ___________________________

Physician: _______________________________ Phone: __________________

Please list anyone besides your emergency contacts who may pick up your child.

Name: _____________________________________ Phone: _______________

Name: _____________________________________ Phone: _______________

Please list any medical concerns, such as allergies, medications, and/or special requirements that your child may have.

_________________________________________________________________

________________________________________________________________CCan we give your child something for pain, if needed?        Yes             No

If yes, what do you prefer? __________________________________________

                                               

                                      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                                           

 

Photography release: From time to time we may take pictures to use for promotional material. Please indicate below if we have your permission to use photos of your child. If “NO” is not circled, we will assume we have permission to use any photograph your child is in.

            Release to use pictures with your child:     circle                 YES                   NO

 

Contact:  Lynn Nania, Director  -  860-824-0393 (h), 860-387-5757 (c), 860-824-0445 (fax), lcnania@yahoo.com

Mailing: Lynn Nania,  35 Undermountain Road,  Falls Village, CT 06031