Youth Silverwood Overnight

Child's Name:*

Child's Gender:*

Female

Male

Please list any allergies:

Birth date:*

Grade of Child in 2017-2018:*

Special Needs:

Please fill out the following information if you are registering a second child.

Second Child's Name:

Second Child's Gender:

Female

Male

Please list any allergies for second child:

Birth date of Second Child:

Grade of Second Child in 2017-2018:

Special Needs of second child:

Parental Information

Parent (1) Name:*

Parent 1 Phone #:*

Area Code

Phone Number

Parent 1 Email:*

Parent (2) Name:

Parent 2 Phone #:

Area Code

Phone Number

Parent 2 Email:

Emergency Contact Name:*

First

Last

Phone:*

Area Code

Phone Number

Release Information:

PHOTO RELEASE:
I hereby give permission for my child to have my childs' photo used on the EUMC website or in the publications of EUMC.:*

Yes

MEDICAL RELEASE:
I hereby give permission for my child to receive emergency treatment (CPR, First Aid) while in the care of EUMC, if necessary. If I can't be contacted, I authorize and consent to medical, surgical, and hospital care, treatment and procedures to be performed for my child by a licensed physician, health care provider, hospital, EMS or aid car attendant when deemed necessary. I waive my right of informed consent to such treatment. I also give permission for my child to be transported by ambulance or aid car to any emergency center for treatment. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child(ren) pursuant to this authorization.*

Yes

Please select the box below and enter the number of children registering:

Silverwood Overnight

Quantity

Total:

Silverwood Overnight Registration