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Summer Camp Registration
Participant's First Name
Participant's Last Name
Age
Participant's Facebook - Identify Facebook Name (If participant does not have a Facebook account, please provide parent or guradian's Facebook name)
Medical Information
Please list any known medical conditions/allergies which may require consideration in the event of an emergency. In none, please note NA.
Please check all that apply. In none, please check NA.
Uses an inhaler
Has an epi-pen
NA
Physician Name
Physician Phone
Would you like to register a sibling for the camp?
Yes
No
Sibling's First Name
Sibling's Last Name
Age
Participant's Facebook - Identify Facebook Name (If participant does not have a Facebook account, please provide parent or guradian's Facebook name)
Medical Information
Please list any known medical conditions/allergies which may require consideration in the event of an emergency. In none, please note NA.
Please check all that apply. In none, please check NA.
Uses an inhaler
Has an epi-pen
NA
Physician Name (If same as other child, note NA)
Physician Phone
Would you like to register another sibling for this camp?
Yes
No
Second Sibling's First Name
Second Sibling's Last Name
Age
Participant's Facebook - Identify Facebook Name (If participant does not have a Facebook account, please provide parent or guradian's Facebook name)
Medical Information
Please list any known medical conditions/allergies which may require consideration in the event of an emergency. In none, please note NA.
Please check all that apply. In none, please check NA.
Uses an inhaler
Has an epi-pen
NA
Physician Name (If same as other child, note NA)
Physician Phone
Insurance & Emergency Contact
Insurance Carrier
Policy Number / Group Number
Emergency Contact - Please identify the FIRST PERSON you prefer for emergency contact (this could be the parent/legal guardian).
First Name
Last Name
Phone
Relationship to Participant
Guradian Information
Legal Guardian #1 First Name
Legal Guardian #1 Last Name
Legal Guardian #1 Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Legal Guardian #1 Phone
Legal Guardian #1 Email Address
Legal Guardian #2 First Name
Legal Guardian #2 Last Name
Legal Guardian #2 Street Address
Street Address Line 2
City
Region/State/Province
Postal / Zip code
Country
Legal Guardian #2 Email Address
Legal Guardian #2 Phone
Waivers/Medical Emergency Release
Confirmation
Guardian for Minors: YES, DAG may list my child/children's medical conditions on Sign In/Sign Out documents and other documents to ensure critical medical information is readily available to the directing staff and parent volunteers. I am aware that this information will be visible to other DAG members/cast.
Guardian for Minors: NO, DAG may not list my child/children's medical conditions on any documents outside of the Membership/Master Paperwork file. I am aware this may delay action in an emergency situation.
In Case of Emergency
Confirmation
I grant permission for a Downriver Actors Guild representative to seek medical treatment for my child
I do not grant permission, cancel my application
*Signature: Digital Signature: by entering your name below, you are effectively providing your signature for 1) your response to accept or reject the authorization to list medical conditions above 2) your response to accept or reject the medical waiver above.
Clear
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