HOT SUMMER COOL TIMES

Primary Phone*

Name/Relationshipphone number
Secondary Phone

Name/Relationshipphone number
Additional Emergency contact*

Name/relationshipPhone Number
Please make sure you answer all calls during program hours and voicemail is set up and not full.
Person/s allowed to pick up child: (Must provide valid ID/DL at time of pick up)*
Enter names, relationship & phone numbers
I understand and agree to the medical release outlined above*

Yes

I understand that HCPR staff can not dispense any medication, whether prescription or over the counter.*

Yes
Physician Information:*

Dr. NameDr. Phone Number
Does your child have any allergies?*

YesNo
If yes list allergy/s:*
If none enter N/A
If yes has your child ever been hospitalized for these?

YesNo
If Yes, does your child carry emergency medications such as an Epi-pen or inhaler?

Yes (I understand my child must be able to self administer. HCPR staff can not dispense any medications, either prescription or over the counter.)No
OTHER PERTINENT MEDICAL INFORMATION: Is there any additional information about your child's health that you think is important or that may impact their ability to participate in this program?*
Is there any additional information we need to be aware of regarding your child that may require accommodations? (Enter N/A if none)*

This health form is correct and complete as far as I know and the person herein described has permission to engage in all event activities except as noted. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes.*

Yes
Is there any additional information we need to be aware of regarding your child that may require accommodations? (Enter N/A if none)*
Media release: Please choose 1.*

I hereby give my consent for the image and likeness of the above named participant to be video taped or photographed for the following uses: Educational/Instructional media, Recruitment/Outreach Media, Development Media, Newsworthy Media Documentation.I do not grant consent
PARTICIPATION WAIVER: I / We the parents and/or guardians of the above named participant in the named HCPR Program, hereby give my/our approval to participate in any and all activities. I/we assume all risks and hazards incidental to such participation, including transportation to and from the activities, and I/we do hereby waive, release, absolve, idemnify and agree to hold harmless the Harrison County Parks and Recreation management and staff, the Harrison County Commission, property owners, sponsors, other participants, from any claim arising out of the injury or property damage to my/our child. The undersigned also assumes responsiblity to read, acquire understanding of and abide by all rules and program objectives.

MEDICAL RELEASE: In the event of any emergency situation every reasonable effort will be made to contact parents/guardians.
In the event of a medical emergency or accidental injury, the undersigned grants permission to HCPR staff to call for emergency care and transportation. Furthermore, authority is granted for the administering of any examinations, diagnostic procedures and treatment deemed necessary by medical professionals.
Parent/Guardian will be responsible for all costs incurred. The undersigned also is responsible to inform the HCPR staff of all pertanent medical information for the participant.

I/we understand that I may be required to produce a birth certificate of the above named child.
Signature (By signing I also affirm that I am the custodial parent and/or legal guardian of registered child)*

Clear
NOTE: This information is collected for the safety of your children. All information is only for use of HCPR and its staff. No information is given out.
Should be Empty: