2011 Summer Cooking Camp Registration Form

Name:

Session:

___ Session 1: 1:30 – 4:30 pm, June 21, Monday – June 25, Friday

___ Session 2: 1:30 – 4:30 pm, August 23, Monday – August 25, Wednesday

Birth Date:

______________________ (kids must be 8 – 14 years old)

Gender:

• Male

• Female

Address:

Contact Information:

Parent /Guardian Name:

Home Phone:

Work Phone:

Cell Phone:

Email:

Company Name:

Emergency Contact Information:

Name:

Home Phone:

Work Phone:

Cell Phone:

Email:

Company Name: 3

Health History:

IMMUNIZATION RECORD - Attach a copy of your child’s Immunization Record - required

ALLERGIES - If YES, give details:

_____________________________________________________________________________

Asthma • YES • NO _______________ Insect Bites • YES • NO _____________

Seizures • YES • NO _______________ Latex • YES • NO ______________

Diabetes • YES • NO _______________

Over the Counter Medication • YES • NO ______________

Antibiotics • YES • NO ______________

Has camper had any operations or serious illness? • YES • NO If YES, explain: _____________________________________________________________________________

Does camper have chronic or recurring illness? • YES • NO If YES, explain: ______________________________________________________________________________

Does camper have any medical, physical, behavioral condition(s) that we should be aware of?

• YES • NO If YES, explain: ______________________________________________________________________________

Does camper take any daily medication(s)? • YES • NO If YES, list medication & reason taking it: ______________________________________________________________________

(prescription & non-prescription)

Doctor ________________________________

Address _____________________________________

Phone _________________________

Permission to Treat in a Medical Emergency:

In the instance of a medical emergency, I understand that Dream Dinners will always attempt to contact the parent/guardian first. I hereby give permission to Dream Dinners staff to seek emergency medical treatment including ordering x-rays, routine tests, or to provide or arrange necessary related transportation for my child/ward. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. In the event I cannot be reached in an emergency, I hereby give permission to the physician to secure and administer

treatment, including hospitalization for my child/ward. If there is a change in the above information, I will promptly notify Dream Dinners Cloverly Street.

I hereby give Dream Dinners staff permission to provide emergency care, as necessary. This completed form may be photocopied for trips out of the store.

Signature of Parent/Guardian: _____________________________________________________

Date ________________________ 4

WAIVER FOR PARTICIPANT AND/BY PARENT

In consideration of your accepting my or my child’s entry, I hereby, for myself, my child, our heirs, executors, and administrators, waive and release any and all rights and claims for damages I or my child may have against Dream Dinners and its representatives, officers, employees, agents, successors, and assigns for any and all injuries suffered by myself or my child on any activity sponsored by these groups. I do hereby grant and give these groups the right to use my or my child’s photograph or image with or without my or my child’s name both single and in conjunction with other persons or objects for any and all purposes including, but not limited to private or public presentations, advertising, publicity, and promotion relating thereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold Dream Dinners harmless of and from any and all liability of whatever nature which may arise out of result from such uses. For the consideration stated above, I further agree that in the event that my child repudiates or attempts to repudiate such release, I will personally indemnity and save harmless Dream Dinners, its successors and assigns, for any and all loss and damage occasioned thereby.

Signature of Parent/Guardian: _____________________________________________________

Date ________________________