SAVE FORM AS: Last name, first name and DOB with no dashes. IE

SAVE FORM AS: Last name, first name and DOB with no dashes. IE: Lawrence, Cindy 12251970
JOHNSON COUNTY PARK AND RECREATION DISTRICT
Ernie Miller Nature Park
Summer Tots and Summer Vacation CAMP
2016 PERSONAL DATA FORM
Child's Full Name:
Child’s Age: _____ DOB: ___/____/____
Week(s) enrolled:
Summer Tots (ages 4-5)
☐6/6
Summer Vacation (ages 6-8)
☐6/6 1pm
☐6/20
☐6/13 9am
☐6/27
☐7/6
☐7/18
☐6/13 1pm
☐7/11 9am ☐7/25 9am
Address:____________________________________ City:____________________ State: ___ Zip: ________
Parent/Guardian:
Home #:
Home Address:
Cell #:
Employer:
Work # & Ext.
Parent/Guardian:
Home #:
Home Address:
Cell #:
Employer:
Work # & Ext.
Emergency contact: _______________________________Phone #:
(Other than Parents)
Relationship:
List Food/Substance Allergies:
List all individuals authorized to pick up your child (other than parents). Photo ID will be required.
Name:
Relationship:
Phone #:
Name:
Relationship:
Phone #:
Name:
Relationship:
Phone #:
(MUST HAVE PHOTO ID TO PICK UP CHILDREN)
Specifically state any physical limitations: Anything special we need to know about your child?
Signature of Parent/guardian: _____________________________ Date: _____________________________
*I attest that the information here provided is complete to the best of my knowledge. Typing my name in this box serves as my signature, for legal
purposes pertaining to JCPRD programs and KDHE requirements.
Emergency Medical Release Form
Written permission for emergency medical treatment must be on file.
I hereby authorize Johnson County Park and Recreation District Staff and/or Ernie Miller Nature Center Staff
who are representative(s) of the above named organization to give consent for any and all necessary
emergency medical care for ____________________________________________ (child’s first and last name)
while said child is in organizations custody.
Complete information regarding health care insurance, if applicable.
Health Insurance Policy Name_________________________________________________
Policy Number/ Member ID___________________________________________________
Physicians Name: _____________________________________ Physicans Phone #: ____________________
Emergency Hospital Preference: _______________________________________________
X____________________________________
_____________________________
Signature of parent/guardian *
Date
*I attest that the information here provided is complete to the best of my knowledge. Typing my name in this box serves as my signature, for legal
purposes pertaining to JCPRD programs and KDHE requirements.
Johnson County Park and Recreation Waiver Statement
WAIVER STATEMENT: The undersigned states that he/she understands that the Johnson County Park and Recreation
District is not and shall not be responsible for or liable for any illness, or injury to person or damage to property
resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in
said program, and the participant and the undersigned, if the participant is a minor or under other legal disability,
hereby forever releases and holds harmless the said Johnson County Park and Recreation District, it's employees, agents
and representatives from any and all claims of any kind that the participant, or the undersigned or their respective
heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program.
NOTICE: By enrolling in this program you hereby acknowledge the Johnson County Park and Recreation District can and
may photograph and/or video tape program participants and then use such images, without payment or any other
consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purpose.
(Registration is invalid without signature.)
I have read and I understand the Waiver Statement.
Signature of Parent or Guardian*
Participant Name
*I attest that the information here provided is complete to the best of my knowledge. Typing my name in this box serves as my signature, for legal
purposes pertaining to JCPRD programs and KDHE requirements.
SAVE FORM AS: Last name, first name and DOB with no dashes. IE: Lawrence, Cindy 12251970
Email form to: mailto:[email protected]