Professional Documents
Culture Documents
8:30 am 5:30 pm
Cash
Check
Credit Card
Debit / MC / Visa
CC #
( ) Bus/Walking
Ages: 7 13 Yrs
Childs Name:
Age:
(W)
(H)
(W)
(H)
Email:
Other Contact:
(Cell)
(H)
Email:
Dads Name:
(Cell)
(W)
Email:
(Circle)
Parent/Guardians Name
Parent/guardians signature
A Special Note to Parents/Guardians:
(1)
(2)
All prescription drugs, except those which must be kept on the camp members person for
emergency use, must be kept and distributed by the BCB staff.
(3)
Check here if there are NO special problems that the BCB staff should be aware of and no
prescription drugs are required on the trip. [ ]
(4)
If any medication or prescription drugs are to be taken by the camp member, list them here
(Name of drug and reason):
___________________________________________________________________
___________________________________________________________________
If your child has a special medical problem, kindly attach a description of that problem to this
sheet.
_____________________________________________
BASIC
CONFIDENT
*Please note that if your child cannot swim they will be required to wear armbands. If armbands are not provided they
will not be allowed to swim.
The undersigned has read and voluntarily signs the release and waiver of liability and indemnity
agreement, and further agrees that no oral representations, statements, or inducement apart from
the foregoing writing agreement have been made.
Date Signed _________________________________
Parent/Guardian printed name _____________________________________________________
Parent/Guardian signature ________________________________________________________
Participant name (please print) ____________________________________________________