CAMPER APPLICATION

Each party agrees that the electronic signatures, whether digital or encrypted, of the parties included in this Agreement are intended to authenticate this writing and to have the same force and effect as manual signatures. Delivery of a copy of this Agreement or any other document contemplated hereby bearing an original or electronic signature by facsimile transmission (whether directly from one facsimile device to another by means of a dial-up connection or whether mediated by the worldwide web), by electronic mail in portable document format (.pdf) form, or by any other electronic means intended to preserve the original graphic and pictorial appearance of a document, will have the same effect as physical delivery of the paper document bearing an original or electronic signature.

The health history given on this application is correct so far as I know, and the named minor on this application has permission to engage in all prescribed program activities, except as duly noted on Page 3. The undersigned do hereby authorize the directors of Royal KIDS Camp #218 or such substitute as they may designate as agent for the undersigned to consent to an X-Ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the minor child named on this application which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp or elsewhere. This authorization will remain effective while the above minor named on this application is in-route to and from or involved or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Director of Royal Family KIDS Camp #218 as legal guardian/social worker/other.

Indicate all known allergies, illnesses, disabilities, physical limitations or medical complications below. Please include the date of illness, severity, and any residual impairment.

Fill in dates of basic immunizations and most recent booster or provide a copy of the Alabama Department of Health Certificate of Immunization.

List all medications (OTC or Prescription) this camper will be taking during camp week. All medications sent to camp must be in the original container with the pharmacy label on it.

I understand that it is my responsibility as caregiver to make sure that all information and instructions are clear concerning the minor child named on this application and that the necessary instructions and dosage(s) for the administration of medication(s) is adequately supplied for the duration of camp. I hereby authorize the staff nurse for Royal Family KIDS Camp #218 to administer the above medication(s) as stated above from: Monday, June 25, 2018 to Friday, June 29, 2018.

I hereby give permission to the registered nurse(s) at Royal Family KIDS Camp #218 to administer/use the following products according to manufacturer’s instructions, or as otherwise specified. I trust and give permission to the registered nurse(s) at Royal Family KIDS Camp #218 to use their best judgment as situations arise, and if in doubt, he/she will call for verification. Please check YES or NO for the medications/treatments listed below.

We need to know some information about this child because at Royal Family KIDS Camp everyone receives: Camp shirts and swim shoes.

Case Worker information is very important. Case Workers are our 1st contact in case of emergency involving a foster child. Please fill in all contact information.