Phone: Camper Information First Name: Last Name: Birthdate (Y-M-D): Allergies and/or Medical Conditions: Behavioral Conditions: Health Card Number (optional): By signing below, I hereby release CKCU and its respective officers, employees, and agents from and against all claims, actions and expenses which may result from or be in any way related to my child’s (or children’s) participation in the CKCU Radio Camp. During the camp it is possible that CKCU will photograph and/or include my child in a video filmed during camp. Please inform the staff if you do not wish photographs or film of your child to be used for promotional material ____________________________ Parent/Guardian Name (please print) __________________ Signature ____________ Date
Phone: Camper Information First Name: Last Name: Birthdate (Y-M-D): Allergies and/or Medical Conditions: Behavioral Conditions: Health Card Number (optional): By signing below, I hereby release CKCU and its respective officers, employees, and agents from and against all claims, actions and expenses which may result from or be in any way related to my child’s (or children’s) participation in the CKCU Radio Camp. During the camp it is possible that CKCU will photograph and/or include my child in a video filmed during camp. Please inform the staff if you do not wish photographs or film of your child to be used for promotional material ____________________________ Parent/Guardian Name (please print) __________________ Signature ____________ Date
CKCU-Radio-Camp-Registration-Form-2017.docx