Dwight – Englewood School Sports Camp Participant Health Form & Waiver

NOTE: This completed and signed form is required for all participants and must be completed before camp begins. .

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Student Info

Student’s Name:*

Name

Date of Birth:*

Select Date ×

Mailing Address*

Address line one

State

Zip Code

Parent Info

Primary Contact

First Name

Last Name

Email Address

Primary Phone*

Phone

Cell Phone

Phone

Work Phone

Phone

Add Secondary Parent

No Yes

First Name

Last Name

Write Here

Email Address

Primary Phone

Phone

Cell Phone

Phone

Work Phone

Phone

Health Form

Additional Emergency Contact:*

Name

Emergency Contact Phone*

Phone

Does your child carry an inhaler, EpiPen or auto injector?*

Yes

Does your child have any allergies?*

Yes (IPlease speak directly with our program director at drop off)

Waiver

Permission for treatment of minors: I give my permission for such diagnostic and therapeutic procedures as may be deemed necessary for the participant by the medical care facility. I understand that the School will make every reasonable attempt to contact me first, time and conditions permitting. I understand I am responsible for charges incurred. I agree that this form will remain in the possession of Dwight-Englewood School, and it will accompany the student to any medical intervention.
Parents/Guardians hereby release, discharge, indemnify, and hold harmless Dwight-Englewood School from any and all losses, financial liability or expenses, obligations, claims, judgments, liabilities (including attorney’s fees) of any nature arising out of, or in consequence of Student’s participation in campus activities, including, but not limited to, damage to property, bodily or personal injuries, illness, loss of companionship or support or death sustained by any person(s) as a result of Student’s actions or any activity or inactivity which Student may cause or contribute to while participating in the program.

Signature of parent or guardian of minor:

Name

Relationship*

Write Here

Dwight – Englewood School Sports Camp Participant Health Form & Waiver

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Student Info

Parent Info

Primary Contact

Health Form

Waiver

Signature of parent or guardian of minor:

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Dwight-Englewood School