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Corporate Kids Events, Inc
• 11276 Edward Dr, Grass Valley, CA 95949 • tel 800-757-3580

Events Consent and Release Form

for Kid Camp at the Pediatric Epilepsy Surgery Conference and Family Reunion

July 19 - 20, 2019

Our policy requires that our records are accurate and up-to-date. We do not share or sell this information.

Date: May 20, 2019

First Participants Name

First Name*

Last Name*

Phone*
First Participants Date of Birth*
I certify that I am 18 years of age or older
First Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
First Participants Signature*
Second Participants Name

First Name*

Last Name*
Second Participants Date of Birth*
Second Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Third Participants Name

First Name*

Last Name*
Third Participants Date of Birth*
Third Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Fourth Participants Name

First Name*

Last Name*
Fourth Participants Date of Birth*
Fourth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Fifth Participants Name

First Name*

Last Name*
Fifth Participants Date of Birth*
Fifth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Sixth Participants Name

First Name*

Last Name*
Sixth Participants Date of Birth*
Sixth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Seventh Participants Name

First Name*

Last Name*
Seventh Participants Date of Birth*
Seventh Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Eighth Participants Name

First Name*

Last Name*
Eighth Participants Date of Birth*
Eighth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Ninth Participants Name

First Name*

Last Name*
Ninth Participants Date of Birth*
Ninth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Tenth Participants Name

First Name*

Last Name*
Tenth Participants Date of Birth*
Tenth Participants Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
Participants 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*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
In the event of an emergency, I hereby authorize any and all medical attention to be administered, to my child (children) as is deemed necessary by an attending physician or nurse. I understand and agree that I am financially responsible for any care so provided. In consideration of the opportunity to have my child (children) participate in the activities sponsored by Corporate Kids Events, Inc., I hereby assume all risks and waive all claims against the corporation, it’s respective officers, director, employees, agents and representatives for bodily injury or death and for damage to or loss of any property directly or indirectly arising from or in connection with any activities involving Corporate Kids Events, Inc. except to the extent directly and solely caused by the willful misconduct of the corporation or its agents. I also understand and agree that management reserves the right to decline or discontinue enrollment based upon the management’s assessment of physical disabilities or medical conditions requiring an amount of attention or medical expertise beyond the company’s formal scope of ability. Corporate Kids Events has my permission to take photos of my family and children at this event. Pictures may be used for digital photo CD and/or customer access via our website homepage and for client and promotion for future events. Corporate Kids Events has my permission to take my child from the childcare room with supervision to use the bathroom, participate in a group game, or take a walk in the hotel, convention center, armory, or event location.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

MEDICAL INFORMATION


Chronic Illnesses

Food Restrictions

Special Needs

Allergies

Insurance Carrier

Current medications

Other Instructions
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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