Order confirmation
number: *
E-mail Address:
*
Childs Name
(First and Last): *
Child is:
*
Home Phone:
*
Address:
*
School:
*
Grade in
Fall 2010: *
Birth Date:
*
Name of Parent/Guardian:
*
Emergency
Daytime Phone: *
Other Parent
Contact #s:
In
the event of illness or emergency, if parents cannot be reached,
is there another local person who may pick up your child and
care for them until you are contacted?
-Name and
Relationship:
-Phone:
Note:
The Cincinnati Parks staff can not administer any type of
medications (including insulin injections and Epi-pens).
Please note
any medical conditions, allergies, medications, or other health
concerns which should be known by your child’s camp leader
or emergency medical personnel. Please indicate NONE if no
medical conditions pertain to your child:
*
If possible,
place my child in a group with: (Note: Please list only one child. We do not guarantee
placement. We can place children with a requested friend only
if both children request each other and are close in age.)
By checking
this box and clicking Submit, I hereby release and save harmless
the Cincinnati Board of Park Commissioners and its employees
from any and all liability for any injuries, loss, or other
claims arising out of this camp and its program. In the event
I cannot be reached in an emergency, I hereby give permission
to the medical personnel selected by the camp director to
administer treatment, including hospitalization, for my child
as named above. I give permission for my child to be photographed
and for his/her picture to be used without identification
or compensation in Park publications.
*
*Parents:
You will be asked to sign this form on the first day of camp.
Please double check that your email address is entered correctly,
as you will receive a confirmation email of what you submit.
(You will
receive an immediate email confirmation of what you submit.)
* Required
