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Passport, Inc. Medical & Photo Release Form

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Parent/Chaperone Cell Phone: *

Home Phone:

Work Phone:
T-Shirt Size:*
If Student, grade prior to this summer:
3
4
5
6
Church with which participant is attending:
Week Attending

Medical Information


Medication (currently using)

Allergies

Are there any dietary allergies we should be aware of? If none, leave this blank.

Please list anything that may require special attention for you or your child. This may include: family crisis situation, physical limitations (mobility, sight, or hearing differences), unusual allergic reactions (food, bee stings), English as a second language, learning or behavioral differences, emotional or spiritual struggles, etc. This information will be handled carefully and will not go beyond the Passport staff. Passport reserves the right to ask that an adult from the group assist an individual during program activities if we consider close individual attention to be in the person's best interest.

Family Doctor *

Family Doctor Address *

City, St, Zip *

Year of Last Tetanus Shot: *
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
A signed copy of this waiver will be sent to the email address you provide.
Insurance

Insurance Carrier (if applicable)

Policy #

Group #
Medical and Photo Release

I do hereby give my permission for myself/my child to receive emergency medical care. In addition, I will not hold Passport, Inc., responsible for any expense, claims, or liability arising from an injury to myself/my child. I also give Passport, Inc. permission to use my/my child's image(s) at camp and in future promotional materials.


Foster parents and guardians adhering to safety rules and regulations, please email a detailed message to photolimits@passportcamps.org if Passport needs to take special precautions to limit or avoid the usage of your child's images of camp participation.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Parent/Chaperone Cell Phone: *

Home Phone:

Work Phone:
T-Shirt Size:*
If Student, grade prior to this summer:
3
4
5
6
Church with which participant is attending:
Week Attending

Medical Information


Medication (currently using)

Allergies

Are there any dietary allergies we should be aware of? If none, leave this blank.

Please list anything that may require special attention for you or your child. This may include: family crisis situation, physical limitations (mobility, sight, or hearing differences), unusual allergic reactions (food, bee stings), English as a second language, learning or behavioral differences, emotional or spiritual struggles, etc. This information will be handled carefully and will not go beyond the Passport staff. Passport reserves the right to ask that an adult from the group assist an individual during program activities if we consider close individual attention to be in the person's best interest.

Family Doctor *

Family Doctor Address *

City, St, Zip *

Year of Last Tetanus Shot: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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