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ADVENTure CAMP
2019 6th Avenue North
Birmingham, AL, 35203
(205) 252-2535
Advent Episcopal School Summer Camp
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ADVENTure CAMP
Home
Day Camp (PreK-4th)
CIT Programs (5th - 10th Grade)
Register
Please complete the following information:
Student Name
*
First Name
Last Name
Date of Birth
*
MM
DD
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Additional Student Name
First Name
Last Name
Additional Student Date of Birth
MM
DD
YYYY
Additional Student Names and Date of Birth
Description of Known Medical Condition(s)
Description of Known Allergies
Student's Physician
*
Physician's Phone Number
*
Medical Information Release
*
1. I hereby authorize Advent Episcopal School ("Advent") to use and disclose the health information contained herein during Advent's Summer Program when such disclosures is in the best interests of the student named above. 2. I understand that the information and records used and disclosed pursuant to this medical information form may include information relating to: human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS); history of or treatment for drug or alcohol abuse; or mental or behavioral health or psychiatric care. 3. I hereby authorize Advent to disclose the medical information contained herein to any emergency medical personnel when, in the opinion of Advent, such disclosure is in the best interests of the students. 4. I understand that to the extent that any recipient of this information is not a covered entity under Federal or Alabama privacy law, the information may no longer be protected by Federal and Alabama privacy law, once it is disclosed to the recipient and, therefore, may be subject to re-disclosure by the recipient. 5. I understand that I may revoke this authorization in writing at any time except to the extent that Advent has already relied on this authorization. I understand that I may revoke the authorization by sending a written notice to Advent Episcopal School, 2019 6th Avenue North, Birmingham, Alabama, 35203, stating my intent to revoke this authorization. 6. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to disclose it. 7. I, the undersigned, understand that this information will be shared with the members of the faculty and staff of Advent to ensure the safety of my child.
Yes, I agree to the statements above.
No, I do not agree to the statements above.
Authorization
*
My child, listed above, has permission to participate in any special activities provided during the Advent Episcopal School ("Advent") ADVENTure Camp Program and I am willing for him/her to take part in all activities offered to him/her as a part of the ADVENTure Camp Program. I hereby waive and release Advent and any of its employees, agents, or representatives from any and all claims to injury to person and property that might arise in connection with my child's participation in the ADVENTure Camp Program. I/We the undersigned, do hereby consent to, authorize and direct Advent to obtain for my child such medical care, treatment, or hospitalization as may be necessary while said child is participating in the ADVENTure Camp Program. Advent publishes student photos on its Website, both on the public side and the private side, and promotional materials/advertising. Student names are never associated with these photos. However, news stories, by default, do show student photos along with their names. I hereby authorize Advent Episcopal School to use and reproduce my child's name and likeness on the public part of the school's Website for news stories. I further release Advent Episcopal School and its officers, agents, servants and employees from any and all claims for damages for libel, slander, invasion of the right of privacy or any other claims based on, arising out of, or connected with the use of said name and likeness. If you desire that your child's photo, even without any name association, may not be used at all, please send an email to the school stating your photo use withdrawal.
Yes, I agree to the statements above.
No, I do not agree to the statements above.
Pick Up Permission
*
I give permission for the following contacts to pick up or drop off my child(ren) (listed above) while participating in the Advent Summer Program.
Yes, I give my permission.
No, I do not give my permission.
Contact 1
First Name
Last Name
Contact 1 Phone Number
*
(###)
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Contact 2
First Name
Last Name
Contact 2 Phone Number
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Contact 3
First Name
Last Name
Contact 3 Phone Number
(###)
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Parent E-Signature
*
Date of Signature
*
MM
DD
YYYY
Parent Phone Number
(###)
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Thank you!