Please print the following information and fill in ALL the information
To Whom It May Concern:
The undersigned does hereby give permission for our (my) son / daughter, _____________________________ to attend and participate in Awana Sparks Camp-a-Rama. I also give permission for our (my) son / daughter to participate in camp activities. The undersigned does also hereby give permission of our (my) son / daughter to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Awana Sparks Camp-a-Rama.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advise of any physician or dentist licensed under the provisions of the Medical Practice Act on the medial staff of a licensed hospital and/or emergency care facility, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. We (I) do herewith authorize the treatment by this authority and is granted only after a reasonable effort has been made to reach us/me the parent(s) and/or guardian(s).
We (I) the undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental service rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
My signature also serves to indicate my willingness to take full financial responsibility for any and all medical services rendered for the named participant. My signature also serves to indicate my willingness for my Health Insurance Company ________________________________ Policy Number __________________________ to be billed for any and all medical fees and services should they be needed.
The undersigned does hereby release and agree to hold harmless the host church (Covenant Baptist Church in Ellicott City, MD), Awana Sparks Camp-a-Rama, the Awana Missionary, Awana Ministry Team members, and Awana Clubs International, and their directors, employees, agents, or representatives from any and all liabilities or claims for personal injury, illness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by our (my) son/daughter that occur on the above date stated and/or while said child is participating in the above named camp program and its activities.
Name of Camper:__________________________________ Date of Birth:_____/_____/_____
___________________________________________________________________
(Parent or Guardian’s Signature)
___________________________________________________________________
(Printed Name of Parent or Guardian)
PLEASE HAVE A WITNESS (21 YEARS OF AGE OR OLDER, NON-RELATIVE) SIGN THEIR NAME AND PUT THE DATE OF THEIR SIGNATURE ON THE LINE BELOW TO VERIFY THE PARENT/GUARDIAN RELATIONSHIP TO THE ABOVE CAMPER, OR YOU MAY HAVE YOUR SIGNATURE NOTORIZED.
___________________________________________________________________
(Witness Signature and Date of Signing)
Address of Camper: __________________________________________________________________________________
City: __________________________________ State: _____________ Phone: (____)_____________________
Family Doctor: _____________________________________________ Phone: (____)_____________________
List any specific medical allergies, chronic illnesses, or other conditions:
____________________________________________________________________________________________
____________________________________________________________________________________________
Emergency phone numbers (other than those listed above):
Phone: (____)__________________________ Contact: _______________________________
Date of last tetanus shot: __________________________________