|
Child's Name:
Child's current grade: Child's birthdate:
Street Address:
City, State, Zip:
Home Phone:
Mother's name:
Work/cell phone:
Father's name:
Work/cell phone:
Please check the days you would like to attend:
Monday,
March 25 - Fun at Camp
Early
drop off
Thursday,
March 28 Fun at Camp (K - 1)
Early
drop off
Late
Pick Up
Thursday,
March 28 Six Flags (2 and up)
Early drop off
Thursday,
March 28 overnight
Friday,
March 29 Adventure Park USA
Early
drop off
Late
Pick Up
Wednesday,
April 3 Sandy Spring Adventure Park
Early
drop off
Late
Pick Up
Please indicate whether you are paying by
check or by PayPal:
Medical insurance Information:
Insurance carrier: Policy number: Phone number:
Medical information:
Allergies/special dietary concerns:
Medication:
The Cougar Camp Program and its representative have my
permission in an emergency when I or my physician cannot be
contacted to authorize care and treatment for my child,
including care and treatment for injuries and illnesses and
administration of medication. The camp representative may
hospitalize and/or secure proper treatment for my child in case
of medical emergency, if in their best professional judgment
further delay may jeopardize the welfare of my child. I give
permission to release pertinent medical information to the
Cougar Camp staff and its representatives on a need-to-know
basis. I give permission to release information from my child’s
medical file in order to facilitate proper medical care. I
hereby waive, and release the Cougar Camp, Melvin J. Berman
Hebrew Academy, and staff from any and all liability for any
injury or illness suffered prior to or while at camp.
Parent signature/date
| 