Author: Sam's Club
Company: Hewlett-Packard Company

Registration Form
NAME___________________________________________
BIRTHDAY_____________________________
AGE_____SEX_____PHONE_(_____)__________________
ADDRESS________________________________________
CITY_____________STATE_________ZIP_____________
CAMP WEEK ______________________

I assume full responsibility for this child - self - family any physical welfare and will not hold the organization liable in case of sickness, accident of any liability.
There is a possibility that your child’s photo will be taken and used for promotional purposes for the camp. If you do not approve of this action, check here ( )

SIGNED__________________________________________(Parent or Guardian)
HEALTH INFORMATION
Birthdate:____________________
Have you had a tetanus shot or booster the last six (6) months?_____
Please indicate:  Hearing(___) Hard of Hearing(___) Deaf(___) Blind(___)

Do you have any chronic conditions such as diabetes, epliepsy, allergies, etc.?  Please explain________________________________________________________________

List physical restrictions:__________________________________________________

Name of your hospital Insurance Co.________________________________________

Plan#____________________________________________

CAMPER'S NAME__________________________________

In case of medical emergency, I understand every effort will be made to contact parents or guardians of campers.  In the event I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize and secure proper treatment for, and order injections or anesthesia or surgery for my child as named above.  I also affirm that the medical information on this form is both complete and correct.
Date____________________________________________
Parent or guardian signature_________________________
Doctor's Name:__________________Phone #__________
My Phone No: Home:_____________Work:_____________