Participant Medical Information and Waiver Form

One Heart Camp (LA Edition) 2021

(please complete ONE FORM for EACH CHILD if registering siblings,
but you only need to fill out contact info on one form for convenience)

Participant's Name

IN CASE OF EMERGENCY CONTACT:

Parent(s)

Phone

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Cell Phone

ALTERNATE CONTACTS:

1. Name

1. Phone

1. Cell Phone

1. Relationship

2. Name

2. Phone

2. Cell Phone

2. Relationship

HEALTH INFORMATION:

Do you have Medical Insurance?

Policy Number

Name of Insurance Company

Group Number

Has this child had any major illness or surgery?

Any current condition requiring medication?

Allergies, Special diets, medical conditions we should be aware of

Code of Conduct Agreement

PARENT AUTHORIZATION and LEGAL WAIVER:

I certify that my answers are true and complete to the best of my knowledge. In the event I cannot be reached in an emergency, I give permission to workshop adult staff to administer over-the-counter medicine as needed and the physician and hospital selected by the adult leader in charge to give whatever medical aid is necessary. In consideration of the activity staff and organization for the effort to provide the children with a nurturing and enriching experience, I hereby agree to assume complete responsibility for any costs, medical or other, incurred by my child while attending this event.

I also understand One Heart Camp will put in place numerous preventative measures and enhanced cleaning protocols to reduce the likelihood of spreading COVID-19, but also know that staff cannot guarantee that my child will not become infected with COVID-19. I acknowledge the contagious nature of COVID-19 and assume the risk that my child, myself, and other family members may be exposed to or infected by COVID-19 by attending One Heart Camp, and that such exposure or infection may result in personal injury, illness, permanent disability or death. I will not legally implicate the event staff, Family Federation (FFWPU-USA), or the facility owner or manager.

I, the undersigned, agree to the terms above.

Print Name

Almost done, where should we send the confirmation?

Name

Confirm Email

Phone Number