Hidden Valley Summer Day Camp 2016 Registration Form

For office use only:
Cash
Hidden Valley Summer Day Camp 2016
Registration Form
Week 1: June 13th through June 17th
Week 2: June 20th through June 24th
Check #_______
Date Received:___/___/____
The Night Crew
The Ectothermic Encounters
Please fill out a separate form for each child registering. ____________________________
Child's first name
_______________________________
Child's last name
Parent(s) /Guardian(s) Name(s): ________________________________________________________________________________
Address: _______________________________________________ City: ___________________________ Zip: ________________
Day Phone: _________________ Home Phone: ___________________ E-mail: _______________________________________
Child's Age: _________ Grade Entering________ School:______________________________________________________
**T-shirt size (please circle your child’s size): Youth:
S
M
L
ADULT:
S
M
L
XL
(T-shirt orders will be placed a month before the program – we may not be able to exactly match the size that is indicated.)
Fee: $100.00 per child for first child, $80 for each additional child in the same household for each week.
All Registration fees are Non-Refundable. You will receive an e-mail confirmation of Registration.
Make checks payable to: Hidden Valley Nature Center. Mail it or return it in person on Saturdays to:
Hidden Valley Nature Center
11401 Arlington Ave.
Riverside, CA 92505
EMERGENCY MEDICAL INFORMATION NATURE CAMP
***Please fill out separate medical forms for each Nature Camp Attendee***
Father's/Guardian’s Name
Work Location
Day Phone
Mother's/Guardian’s Name
Work Location
Day Phone
Babysitter's Name
Phone
Name of persons authorized to take child from the facility (this child will not be allowed to leave with any other person without written authorization from parent or guardian).
Name:_________________________________________________ Telephone:__________________________________ Relationship:____________________________________
Name:_________________________________________________ Telephone:__________________________________ Relationship:____________________________________
Name:_________________________________________________ Telephone:__________________________________ Relationship:____________________________________
[(We), the undersigned, parent(s) of_______________________________________, a minor, do hereby authorize the Riverside County Regional Park
and Open-Space District, its adult agents and employees, into whose care said minor has been entrusted while attending programs at Riverside County
Regional Park and Open-Space District and participating In said program activities, to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or
treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and/or surgeon
licensed under the provisions of the Medical Practice Act, or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment
and hospital care to be rendered to said minor by a dentist licensed under the provision of the Dental Practice Art.
It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide
authority and power on the part of the Riverside County Regional Park and Open-Space District, its adult agents and employees, to give specific consent to
any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist, in the exercise of his best judgment, may deem advisable.
It is understood that I, the parent, will assume financial responsibility for costs incurred for treatment or hospital care. This authorization Is given pursuant to
the provision of Section 25.8 of the Civil Code of California.
The undersigned is (are) person(s) having the legal custody of, or is (are) the legal guardians of said minor:
Father/Mother’s Signature:_________________________ Legal Guardian's Signature:
Date:________
Specific information or instructions to Doctor or Nurse:_________________________________________________________________________
Allergies: _________________________________________________________________________________________________________
Date of last Tetanus: __________________ Current Prescriptions: _________________________________________________________
Physician: ______________________ Physician's Phone Number: ____________________________________________________________
Hospitalization Name and Policy Number:______________________________________________________________________________