EmailMe Form - Metro Parks Day Camps

Program your child will be attending: *

Titlow Spring Break Camp, 6-12 yrs (April 1st - 5th)

Norpoint Spring Break Camp, 6-12 yrs (April 1st - 5th)

Titlow Summer Day Camp, 6-12 yrs

Norpoint Summer Day Camp, 6-12 yrs

Wapato Summer Day Camp, 6-12 yrs (July 8th - Aug 2nd)

Child's Name *

First Last

Child's sex *

Male

Female

Child's Age *

Child's Date of Birth *

Parent/Guardian Name *

First Last

Phone *

### - ### - ####

Best number to be reached during program hours

Phone

### - ### - ####

Alternate phone number to be used during program hours

Parent/Guardian's Name

First Last

Phone

### - ### - ####

Best number to be reached during program hours

Phone

### - ### - ####

Alternate phone number to be used during program hours

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Email *

EMERGENCY CONTACT INFORMATION: Name, Phone Number and Relationship to participant of persons to be notified in case of emergency or authorized to pick up. (other than Parent/Guardian) *

I/we have authorized the following person(s) to pick up my/our child in my/our absence. I/we understand that if one of the following named individuals is authorized to pick up my/our child and staff members can request them to show photo identification prior to release of the child. Staff will not release the participant to any person not listed on this form.

Regular Medical Care Provider (Name and phone) *

Hospital Preference in case of injury or emergency

Current Medications

Disabilities/Significant Illness/ Behavior Issues

Allergies

Please note: if your child is allergic to sun block you will need to provide your own with the child's name on it.

CONSENT TO BE PHOTOGRAPHED *

Yes

No

I/We consent and authorize Metro Parks Tacoma to use my/our child’s name and photograph for public relations purposes related to Metro Parks Tacoma

I/WE CERTIFY THAT THE INFORMATION I/WE PROVIDED ABOVE IS TRUE AND CORRECT, AND THAT I/WE HAVE READ THE FOREGOING CONSENT TO PARTICIPATE AND HOLD HARMLESS AGREEMENT AND AGREE TO ALL THE TERMS AND CONDITIONS OF THIS AGREEMENT. *

TYPE IN PARENT/GUARDIAN NAME FOR THE ELECTRONIC SIGNATURE.

CONSENT TO PARTICIPATE/HOLD HARMLESS
I waive all rights and release all claims that might be had against the Metropolitan Park District of Tacoma, its hired or contracted instructors, and their employees and agents, for any and all injuries or losses which may be suffered because of my participation or my child’s participation in the above activity offered by the Park District, in consideration of permission of the Park District to participate in the activity.

I consent to my child’s participation in the activity/program of the Metropolitan Park District of Tacoma, and authorize the District and its employees or agents to provide emergency medical treatment for my child or on my behalf. To the best of my knowledge, my child has no physical or other conditions which would interfere with his/her participation.

AUTHORIZATION FOR EMERGENCY TREATMENT
I/We hereby freely and voluntarily authorize the Metropolitan Park District of Tacoma to request and obtain emergency medical care at my/our expense for my/our child from such medical care provider as is immediately available in any situation which department employees or agents determine such care is required.

PICK UP POLICY
I/We understand that my/our child must be picked up by 6 p.m. each day my child attends the program.