Girls Empowerment Camp Registration

Camper Information

Date of this Application

Is the Camper under 18?

T-Shirt Size?

First Name

Middle Name (if applicable)

Last Name

Birthdate

Address

City

State/Province

Zip/Postal

Primary Phone

Secondary Phone

Email

School

School City

Is the applicant a Fresno Unified School District Student?

Parent / Guardian Information for Campers under 18:

Camper Emergency Contact Information

Medical Insurance Information

First Name of Insured

Middle Name (if applicable)

Last Name

Address of Insured

City

State/Province

Zip/Postal

Insured’s Occupation

Insured’s Address

Insured's Address

City

State/Province

Zip/Postal

Policy Number

Name of Family Doctor

Address of Family Doctor

City

State/Province

Zip/Postal

Phone

Hospital of Choice

Hospital Address

City

State/Province

Zip/Postal

Required Needs

Authorization to Treat Minor

I/we the undersigned camper or parent/s or legal guardian of minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable, rendered under the general or special supervisor of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practices Act, or a Dentist licensed under the provisions of the Dental Practices Act, and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization, given in advance of any specific diagnosis, treatment or hospital care being required, is given to provide authority and power to render care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withhold if the undersigned cannot be reached.

Minor Name

List any medical conditions/treatment restrictions below.

The above information is correct to the best of my knowledge.

Signature of Camper or Parent/Guardian

Clear

Signature of Camper or Parent/Guardian

Print Name

Date of Signature

Address of Camper or Parent/Guardian

City

State/Province

Zip/Postal

Primary Phone

Secondary Phone

Girls Empowerment Camp Waiver and Release of Liability

For and in consideration of the participation in the Girls Empowerment Camp of the City of Fresno, I/we acknowledge and agree that:

a. The City of Fresno does not maintain health insurance for injuries to the participants that may arise out of involvement in the Girl’s Empowerment Camp.

b. My child and I/we realize that participation in all Girls Empowerment Camp activities and events are voluntary and as such volitionally enroll her in accordance with and subject to the following terms:

c. My/My child’s participation may present risks of bodily injury, dismemberment, death, and other loss including damage to property.

d. I/we knowingly and freely assume all such risk.

e. The undersigned camper/parent(s)/legal guardian(s) do release, hold harmless and promise not to sue the City of Fresno, its officers, agents, employees, with respect to any and all such injury, dismemberment, property damage, death or loss, except that injury or loss which results from gross negligence or willful or wanton misconduct of one or those individuals or organizations.

f. I/we will inform my child that he/she must follow all Girls Empowerment Camp safety rules as well as any other rules or directions given during participation in the program.

g. Unless prior arrangements are made, the City of Fresno shall not be held accountable for the safety of participants after program hours.

h. I/we hereby give to the City of Fresno the absolute and irrevocable right and permission to photograph, film, videotape, or record my children’s likeness and/or voice and to use the results and proceeds thereof on the Fresno Fire Department websites or for outreach and/or educational material produced for the Fresno Fire Department.

First Name

Middle Name (if applicable)

Last Name

Birthday

Signature of Camper or Parent/Guardian

Clear

Signature of Camper or Parent/Guardian. This is to certify that as a parent/guardian of this participant, I do consent to his/her waiver and release as set forth above.

AUTHORIZATION FOR MEDICAL TREATMENT OF A MINOR

In accordance with California Family Code Section 6910, I/we, the parents and/or guardians give authorization to a physician(s) and/or surgeon(s), licensed under the provisions of the Medical Practice Act, for said camper, to receive care and/or emergency medical treatment when necessary. I (we) understand and agree that any expenditure incurred for the care and transportation of the above named minor is my responsibility during the period of November 6, 2020.

Camper Name

Signature of Camper or Parent/Guardian

Clear

Signature of Camper or Parent/Guardian

Print Name