Solicitation Form

Raiz Summer Camp

Camp Health Information and Releases.
Participant Name*

First NameLast Name
Birth Date

MonthDayYear
Class Completed*
Camper's School*
Email For Camp Information*
Parent/Guardian Name*

First NameLast Name
Who is authorized to drop & pick up child?*
Authorized Pick Up Name*

First NameLast Name
Authorized Pick Up Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Pick Up Phone Number*

Area CodePhone Number
Relationship to child*
GENERAL HEALTH QUESTIONS: (Click box)
Had recent injury,illness or infectious diseaseHad Chronic or recurring illness/conditionEver been hospitalized?Have frequent headaches/head injury
Been knocked unconscious?Passed out during or after exercise?Skin problems?(rash,itchy)ADHD
AsthmaEating DisorderMedical AssistanceEmotional DifficultyOther
Releases and Authorizations
I agree*

I give the Raiz camp organizers permission to release my child as indicated. I understand any changes to this information must be printed out and emailed to drsetiquetteconsulting@gmail.com.Treatment/ Emergency care – I hereby give permission to the emergency care physician and/or Raiz Camp director to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event, I cannot be reached in an emergency I hereby give permission to the physician selected by the Raiz Camp supervisor to secure and administer treatment, including hospitalization, for the person named above.Field Trip and Transportation release – The Raiz Camp Organizer has permission to take my child on all pre-arranged field trips indicated as part of the program my child is registered for. This includes off site outings.Photo/video release – I give permission for my child to be photographed and/or interviewed for promotional purposes.
I agree*

Informed Consent - I understand that camp activities can sometime have inherent risks and I hereby assume all risks and hazards incident to my family’s participation in Raiz Camp activities. I further waive, release, absolve, indemnify and agree to hold harmless the Raiz Camp, the organizers, volunteers, supervisors, officers, directors, participants, coaches, referees, as well as, persons or parents transporting participants to and from activities from any claims or injury sustained during my child participation in the summerprogram.I certify that my child is in good health and is amiable to normal discipline necessary for a successful group experience. I also understand that the deposits are non-refundable and will hold my child’s spot until the balance is due. Registration is not guaranteed until the balance is paid two weeks before the first day of the summer session. Failure to pay the balance, when due, could result in cancellation of my registration. I also understand if I do not give proper notification, all money paid will not be refunded for the summer program. We agree to honor the behavior policies of the Raiz day/sleep camps and understand that it is at the discretion of the camp director to suspend or dismiss campers from the program due to inappropriate behavior.
Parent / Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Raiz Summer Camp

GENERAL HEALTH QUESTIONS: (Click box)

Releases and Authorizations