PARTICIPANT INFORMATION/MEDICAL AUTHORIZATION/HOLD HARMLESS WAIVER

   

High Adventure Camp

*Required
*Participant's Name:
*Gender:

*Date of Birth:
*Age:

*Current Grade:
*Home Phone:

*Parent/Legal Guardian Work/Cell Phone:
*Address:

*City:
*Zip:

*Email:

*Physician's Name:
*Physician's Phone:

*Person to contact in an emergency:
*Relationship:

*Emergency Contact Phone:
*Can your child swim and/or does he/she have concerns regarding exposure to the water (please explain)? :

*Special medical conditions (allergies, medications, special needs or disabilities, etc.):


NOTE: Please provide the department with allergy information; especially, to bee stings, since this is an outdoor program, and provide your child with an Epi-pen (to be SELF-ADMINISTERED - department personnel is not authorized to administer), if this is appropriate for your child's care.


AUTHORIZATION FOR MEDICAL TREATMENT

*I authorize minor medical treatment, such as: ice packs, band-aids, etc.:

In the event that emergency medical or dental treatment is needed, I permit and authorize the Town of Queensbury Parks and Recreation Department representative/vendor and/or Program Supervisor to seek and provide such treatment in my absence.

*Signature of Parent or Legal Guardian :
*Date:


By providing my signature below, I have carefully reviewed the health information above and attest to its accuracy and consent to my child's participation in the aforementioned program.

Hold Harmless Agreement

The undersigned hereby agrees to indemnify, save harmless, and waives liability of the Town of Queensbury, the Town Board, the Parks and Recreation Department, employees and volunteers thereof, for any responsibility should an accident or injury occur to the undersigned participant as a result of participation in any program sponsored by the Queensbury Parks and Recreation Department or while using recreation program facilities.

*Signature of Parent/Legal Guardian or Participant (if age 18 and over):
*Date:

*Passcode:
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