English Form Efec Summer School (Page 2 of 3) in pdf

Emergency C ontact I nformation:

13. Emergency C ontact N ame:

14. Emergency C ontact R elationship:

15. Emergency C ontact p hone:

16. Please l ist t hose a dults t o w hom y our c hild m ay b e r eleased. W e w ill o nly r elease y our c hild t o a n

individual l isted:

17. How w ill y our c hild g et h ome f rom o ur p rogram?

18. Physician n ame:

19. Physician p hone:

Medical E mergency P olicy

In t he e vent t hat I c annot b e r eached i n a n e mergency, I a gree t o a ccept a ny a nd a ll d eterminations o f n eed f or

medical a ssistance a nd/or a dministration o f m edical a ttention d eemed n ecessary b y S ummer S chool o f R ock

representatives. I h ereby g ive p ermission t o t he m edical p ersonnel s elected b y S ummer S chool o f R ock

representatives t o s ecure a ny a nd a ll m edical, h ospitalization, d ental, a nd/or s urgical t reatment. I n t he e vent

that s uch m edical a ttention i s n eeded f rom a h ealthcare p rovider a ll c osts s hall b e t he r esponsibility o f t he

parent o r g uardian.

Yes, I a gree

No, I d o n ot g ive m y p ermission

Media R elease

I h ereby g ive S ummer S chool o f R ock D ay C amp a nd E FEC t o u se f ilm, v ideotape, a nd/or p hotographs o f t he

above m entioned m inor f or l awful p romotional a nd i nformational p urposes.

Yes, I a gree

No, I d o n ot g ive m y p ermission

Agreement t o W aive L egal R ights

In c onsideration o f b eing p ermitted t o t ake p art i n t he a ctivity s et f orth h erein, I e xpressively a gree a s f ollows:

I h ereby a cknowledge t he a ctivity s et f orth h erein c ontains d angers a nd r isks a nd m ay r esult i n i njury t o t he

participant. I h ereby a ssume a ll r isks o f p ersonal i njury o r d eath a nd p roperty d amage f rom a ny c auses

whatsoever a rising w hile m y c hild o r I a re p articipating i n s uch a ctivity. I o r m y c hild a re i n g ood h ealth a nd

physically a ble t o p articipate i n s aid a ctivity. I a gree t o w aive a nd r elease t he E ducation F oundation o f E agle

County a nd t heir t rustees, e mployees, a gents, s ervants, v olunteers, a nd a ll r epresentatives a nd s ponsors f rom

any i njury I o r m y c hild m ay s ustain o r b y t he u se o f e quipment I m ay u se a t L ittle B each A mphitheater.

Yes, I a gree

No, I d o n ot g ive m y p ermission

Parent/Guardian S ignature:

To c omplete r egistration, r eturn t his f orm v ia m ail t o P O B ox 1 8533, A von, C O 8 1620 o r s can a nd

email t o

w ith y our p ayment o f $ 200.

Page 2 of 3

English Form Efec Summer School Page 2