Day Camp Waiver

if more than one child is being signed up, you must put
in each childs name and age

Register:

Birthdate *
Birthdate
If signing up more than one child, please fill out information below: (name, gender, birthdate)
Please fill in all sections if you are signing up a second child
Birthdate
Birthdate
Please fill in all sections if you are signing up a third child
Birthdate
Birthdate
Parent or Guardian Information
Primary Contact Name *
Primary Contact Name
List primary contact's phone numbers.
Home Address *
Home Address
List names and phone number of people who you authorize to pickup your child (other than you)
Emergency Medical Information
PERMISSION IS GIVEN TO ONE WITH HEART FOR THE FOLLOWING: IN AN EMERGENCY, ONE WITH HEART HAS MY PERMISSION TO OBTAIN MEDICAL TREATMENT FOR MY CHILD, CALL AN AMBULANCE OR TRANSPORT MY CHILD TO ANY AVAILABLE PHYSICIAN OR HOSPITAL AT MY EXPENSE, WITH THE FOLLOWING RESTRICTIONS (IF APPLICABLE) MY CHILD MAY BE GIVEN MEDICATION. I UNDERSTAND THE MEDICAL AUTHORIZATION FORM MUST BE COMPLETED AND SIGNED PRIOR TO ADMINISTERING. I UNDERSTAND I MUST CLEARLY COMMUNICATE ANY MEDICATION ADMINISTRATION INSTRUCTIONS AND PERMISSION TO OWH STAFF PRIOR TO CAMP. MY CHILD MAY PARTICIPATE IN ONE WITH HEART POEKOELAN CENTER FIELD TRIPS. I UNDERSTAND VAN OR PUBLIC TRANSPORTATION MAY BE USED. MY CHILD MAY PARTICIPATE IN SWIMMING OR OTHER WATER ACTIVITIES. MY CHILD MAY BE PHOTOGRAPHED FOR WITHOUT ANY PERSONAL IDENTIFIERS IN MARKETING MATERIALS AND MEDIA PROMOTING THE SCHOOL.
Physician's Phone *
Physician's Phone
Dentist's Address
Dentist's Address
GET UPDATES AND INFORMATION ABOUT ONE WITH HEART BY SIGNING UP FOR THE E-NEWSLETTER
I would like to know more about: (Check all that apply)