Man Camp Liability Form

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A parent or guardian is required to fill out this form for every child who attends Man Camp. Once this form has been filled out, it does not need to be filled out again, unless your information has changed.

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Child's Name

First

Last

Child's Birthday

(MM/DD/YYYY)

Child's Gender

Child's Grade

Child's Home Address

Home Address 2

City

State

Zip Code

Parent/Guardian Name

First

Last

Parent/Guardian Email

Parent/Guardian Phone

Emergency Contact Name

First

Last

Emergency Contact Phone

Emergency Contact's Relationship to Child

Please list any allergies the child has:

Please list any medications the child is regularly taking.

Please list any special instructions for the child.

In case of an emergency and BHH cannot reach me by phone, I give consent for my child to be taken to the closest hospital. I give consent by typing my name below:

Name of Child's Primary Physician

First

Last

Child's Primary Physician Phone

Trusted People for Pick Up

Rules of Behavior (read below)

Rules of Behavior

The overseeing Leader is responsible for maintaining such behavior in the group, and has authority to direct offenders to be picked up by their parent/guardian. The parent/guardian will bear all expenses for picking up their child.

Behavior that is not tolerated includes, but may not be limited to:

- Fighting, harassment, continued coarse speech or behavior

- Possession of any weapon or dangerous object

- Possession of tobacco, alcohol, or controlled substances

- No one is to stray from the group. In the event that someone becomes separated by accident, they must make every effort to immediately rejoin the group.

- Respect for and compliance for event/facility rules

*Safe and moral conduct is mandatory for every participant at every event.

Medical Consent (read below)

Medical Consent

As the Parent/Legal Guardian of (child listed above), I authorize Broken Halos Haven, into whose care the minor has been entrusted, to consent to medical or dental treatment and/or care. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, and is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment may deem advisable.

By typing my name below, I give my consent to all of the above.