Camp Good Days

WNY Monthly Program Permission Slip

* Denotes Required Field

*I am the legal Parent / Guardian, named below, of the child(ren) participating in this event and I am authorized to complete this form.

* Event:

Event Date:

Event Time:

*Has any information changed with your health insurance provider?

Yes

If yes:

CHILD 1: Child's Name and Date of Birth:

CHILD 2: Child's Name and Date of Birth:

CHILD 3: Child's Name and Date of Birth:

CHILD 4: Child's Name and Date of Birth:

Please list any additional children attending and their date of birth (separate each child with a line space):

* Home Address:

*Emergency Phone Number(s):

Parent / Guardian Email:

*I understand it is my responsibility as the parent/ guardian to inform CGD of any dietary restrictions, allergies and special needs of child prior to this event

YES

*Please list any dietary restrictions, allergies or special needs pertaining to child:

*Please list any special needs (i.e. behavioral: ADD, ADHD, autism, physical: uses wheelchair, walker, weakness, needs help with walking, etc) pertaining to your children attending:

Medications (please include any medication routinely taken, including inhaler for asthma, over the counter and chemo). Please List the childs Name, Dose, Route, Schedule. Please Indicate If Your Child Is Currently Undergoing Cancer Treatment.

Participation and Audio-Visual Authorization:
I hereby give permission for the above named child(ren) to participate in the stated activity, and agree to the following:

*a. release Camp Good Days and Special Times, Inc. and everyone involved of all liability or claims associated with this event.

YES

NO (Please remind CGD staff)

*b. release Camp Good Days and Special Times, Inc. and everyone involved of any liability in association with media coverage. Also, I give permission for any photographs to be used for publicity to promote Camp Good Days & Special Times.

YES

NO (Please remind CGD staff)

Emergency Medical Authorization:
Purpose: to enable parents or guardians to authorize the provision of emergency treatment for children who become ill or injured while under Camp authority, when parents or guardians cannot be reached.

	*If in the event that the designated preferred practitioner is not available, another licensed physician will be called. If hospitalization is necessary I request transfer of my child to the following hospital or any hospital reasonably accessible:

	*I also agree that in case of injury to my child requiring medical attention that the following desiganted accident and hospitalization Insurance will be used to pay any expenses connected with injury. (Please Designate)

WNY Monthly Program Permission Slip

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