ECO CAMP EMERGENCY INFORMATION 2011

Name ________________________________ Birthdate ____________ Gender: M F Grade Entering Fall ’11 _______

Child resides with: Mother Father Both Other __________________________________________________

Parent/Guardian __________________________________ Address ___________________________________________

Home # __________________________ Work #________________________ Cell # ____________________________

Emergency Contact _____________________________________ Relation to Child _______________________________

Home #__________________________ Work # ________________________ Cell # _____________________________

Emergency Contact _____________________________________ Relation to Child _______________________________

Home # __________________________ Work # ________________________ Cell # ____________________________

Family Doctor ______________________________________________Office Phone ______________________________

Insurance Company __________________________________________ Policy # ________________________________

Allergies ___________________________________________________________________________________________

Medications ________________________________________________________________________________________

Medical/Other Conditions _____________________________________________________________________________

Persons Who May Pick Up Your Child ____________________________________________________________________

Persons Who May NOT Pick Up Your Child ________________________________________________________________

Other Important Information ___________________________________________________________________________

ECO CAMP RELEASE FORM

My child _____________________________________________________ may participate in Eco Camp:

Session _____________________________________________________ from ________________ to _______________

_____ I understand that participation in Eco Camp will include transportation to and from activities, either by

vehicle or on foot, and authorize Eco Camp staff persons to supervise this transportation.

_____ I give permission for my child’s photograph to be used for publication purposes (website, press releases,

photo sharing sites, posters, etc.)

_____ I DO NOT give permission for my child’s photograph to be used for publication.

_____ I give permission for Eco Camp staff to administer basic first aid when necessary. In case of emergency, staff will determine the seriousness of the situation, and either notify parent or guardian, or call 911 immediately, and then notify parent or guardian.

Participant assumes all of the ordinary risks normally inherent to the nature of the activities and events to be conducted and agrees that Happy Dancing Turtle and its staff or other persons conducting such activities shall not be responsible for any damages or injuries resulting to participant in the absence of gross negligence.

____________________________________________________ _______________________________

Parent/Guardian Signature Date