Name: Healthy Pet Clinic
Start: 2019-07-20T15:00:00+00:00
End: 2019-07-20T18:00:00+00:00
Location: Humane Society of Charles County

If you are human, leave this field blank.

Child (Camper) Name *

Child (Camper) Age *

Parent/Guardian Name *

Parent/Guardian Email *

Mailing Address *

Phone Number *

EMERGENCY CONTACT NAME & RELATIONSHIP TO FAMILY/CAMPER (If parent/guardian cannot be reached) *

EMERGENCY CONTACT PHONE NUMBER *

HEALTH HISTORY (Explanation of any checked boxes above) *

List Any Medications that the Camper is currently taking *

State or Territory in which the Child Resides:

Is this child exempt from any immunizations? No__ Yes__ *

Yes

If you answers YES to above question -- Please List the Immunizations they are exempt from.

Does the Camper reside outside of the United States, a United States territory, or the District of Columbia *

Yes

IF YES to Question Above -- What Country Does the Child Reside?

Has the Camper had any serious injuries and/or operations (please explain) *

HEALTHY INSURANCE (Please provide Company, Policy Number, Family Physician, Phone Number of Physician) *

EMERGENCY AUTHORIZATION (By checking the "I Agree" box, you have given permission to the Humane Society of Charles County and/or any contact person listed above authorization for treatment for your child in the event that we cannot reach you in an emergency) *

I Agree to Emergency Authorization

SUMMER "ANIMAL INVESTIGATION " CAMP SELECTION BY AGE -- (select all that your camper will be attending) *

Ages 5-8 - July 29-August 2, 2019

Ages 7-12 - July 8-July 12, 2019

Ages 7-12 - July 22-July 26, 2019

Ages 7-12 - August 5-August 9, 2019

Ages 7-12 - August 19-August 23, 2019

Ages 11-14 - July 15-July 19, 2019

Ages 11-14 - August 12-August 16, 2019

T-SHIRT Size (select one size)

Youth Large

Adult Small

Adult Medium

Adult Large

OUTDOOR ACTIVITY INFORMATION -- By checking the "I Agree" box, you provide your consent for the camper to apply either sunscreen and/or bug spray for any outdoor activities. If for any reason you do not agree, please contact chanson@humanesocietycc.org *

I AGREE

I DO NOT AGREE, please contact the parent/guardian!

VISIT TO VET CLINIC & MEDICAL PROCEDURES: By Checking the "I Agree" box, the parent/guardian provides consent for the camper to visit the vet clinic and observe medical procedures at the discretion of the Humane Education Staff Member. If for any reason you do not agree, please contact chanson@humanesocietycc.org *

I AGREE

I DO NOT AGREE, please contact the parent/guardian!

GENERAL RELEASE AGREEMENT: By Checking the “I Agree” box (you understand the following: FOR CONSIDERATION which is hereby given and received and acknowledged as sufficient between the parties, you hereby certify that you are the parent or legal guardian of (“Camp Participant”) and you give your permission for him/her to participate in the Humane Society of Charles County, Inc. Summer Camp program wherever said program occurs, including transportation from one location to another. Regarding participation in said program, you hereby release and discharge, for yourself and the Camp Participant, and for your heirs, representatives, executors, administrators, successors and assigns and do hereby remise and release and forever discharge the Humane Society of Charles County, Inc. (“Releasee”), its officers, directors, agents, employees, independent contractors, parent and subsidiary corporations, and all other entities in any way related to Releasee, and all other persons however associated with Releasee, in any capacity, their heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, rights, judgments, claims and demands of whatever kind, including, but not limited to any claims in law or in equity, known or unknown, which you and the Camp Participant now have or may hereafter have, now or in the future, including any legal liability of Releasee arising from or by reason of any damage, compensatory or punitive, known or unknown, foreseen or unforeseen, which heretofore have been or which hereinafter may be sustained by your or the Camp Participant, arising or any way relating to any and all claims and actions. This is affective the date of your registration, and the date that the “I Agree” box is checked. If you any reason you do not agree, please contact chanson@humanesocietycc.org *

I AGREE

PHOTO RELEASE By Checking the “I Agree” box, you hereby understand that you are the parent or legal guardian of the Camp Participant and hereby give the Humane Society of Charles County, Inc., your permission to take photos of him/her. You acknowledge that these photos are the property of the Humane Society of Charles County, Inc., and may be used by them for any purpose consistent with their mission statement, including but not limited to advertising and marketing. *

I AGREE