This form must be completed and signed to complete a camper's registration and for the camper to be allowed to check in

and participate in camp activities.

School _______________________________________  Group Director  (if applicable) ____________________

Camp Attending _______________________________Dates _________________________________________

Student  Name ________________________ Social Security Number:  ______________ Birthdate ____________

Age ___  Sex ___  Address ___________________________________________________________________

Name __________________________ Home Phone __________ Work Phone ____________ Cell ___________

Address ____________________________________________________  Relationship  ___________________

List any medical alerts and/or prescription medication (with doses) currently taking _________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Health Insurance Provider ___________________________________ Policy Number ___________________

I hereby give my permission for a qualified physician, athletic trainer and/or hospital emergency room to administer necessary healthcare in the case of an accident and/or emergency.  In addition, I acknowledge that I have read and understand all information provided.

I hereby hold Jacksonville State University harmless for any/all injuries or damages for the above child's participation in camp activities and I do, for myself, my heirs, executors and administrators, remise, release, waive and forever discharge Jacksonville State University and all of its officers, agents and employees, acting officially or otherwise, from all claims demands, actions, or causes of action, on account of any injury, death or property damage which may occur at any time or for any cause during their participation in a Jacksonville State University camp/event.  

It is agreed that this waiver of liability is submitted to JSU as an inducement to include the said student in this event and that this agreement is signed as the undersigned's free and voluntary act with full knowledge of the contents of the agreement.

Parent _______________________________                       Date ___/___/___

A signature by the student indicates a promise to attend the camp noted above.  The Group Director (where applicable) signature indicates approval of this student's participation and confirms that the Group Director will provide appropriate supervision of the student(s) during the entire course of the event.  Provide both signatures for participation:

Student _______________________________________      Group Director ____________________________