MERCER COUNTY BEHAVIORAL HEALTH COMMISSION, INC
MERCER COUNTY BEHAVIORAL HEALTH COMMISSION, INC.
MERCER COUNTY CAMP K.I.D.S.
2015 REGISTRATION FORM
Child’s First Name: ______________________ Middle Initial: _____ Last Name: _______________________
Home Address: ____________________________________________________________________________
Street Address City State Zip
Date of Birth: _______________ Entering Grade: Circle 5 or 6 Sex: Circle Male or Female
Circle one T-Shirt Size (Adult Sizes): S M L XL XXL
Race: (Optional) ( Caucasian/White ( African American ( Native American
( Hispanic/Latino ( Asian or Pacific Islander ( Multi-Racial
( Other (please list) __________
I, _________________________________________ am the legal Parent/Guardian of the above listed child who resides with me at the above listed address. I can be contacted at the following phone numbers.
Home Phone No.:________________________ Business or Cell Phone: _____________________________
Other responsible adults that can be contacted:
1. Adult Name: _______________________________Phone:_______________Relationship:______________
2. Adult Name: _______________________________Phone:_______________Relationship:______________
Child’s Medical Information:
Family Doctor: _______________________________
Phone: ____________________________
Hospital: ____________________________________
Medical Insurance Carrier: __________________________________________________________________
Identification Number: ____________________________ Group Number: ____________________________
Member's Name: __________________________________________________________________________
Medical History: Allergies, medicine, chronic or existing diseases or medical problems (diabetes, epilepsy, etc.):_____________________________________________________________________________________
Any Medicines your child is currently taking: ____________________________________________________
Recreational or Dietary Restrictions: ____________________________________________________________
Other important information: __________________________________________________________________
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For Medical Treatment of a Minor:
I authorize the Mercer County Behavioral Health Commission Prevention staff person, the School District Personnel, an adult, to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment, and/or hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine in the State of Pennsylvania, should Mercer County Behavioral Health Commission or the School District Personnel be unable to contact the name of emergency individuals.
Parent/Guardian Signature: _____________________________________________Date______________
For Use of Picture and/or Voice
I do hereby give my written consent to the Mercer County Behavioral Health Commission, Inc., Mercer, PA to
Use the above named child’s picture and/or voice for slide or film video tape purposes including the use of said pictures on television and in magazines, newspapers, educational materials and on the internet, whenever, wherever and in whatever manner they shall desire, consistent with good taste which will not be derogatory, degrading or detrimental to me in anyway. I understand that I will not receive any compensation, neither now or in the future for the above.
Parent/Guardian Signature: ______________________________________________Date______________
General Consent:
In providing this information, I agree to hold harmless the Mercer County Behavioral Health Commission, Inc., the School District Personnel and its staff from any injuries, accidents, etc., that may occur with the child participant named above while participating in the program. I give permission for my child to participate in the below listed activities.
Parent/Guardian Signature: ______________________________________________Date______________
Important Notes:
• Summer 2015 Field Trips include an evening Mahoning Valley Scrappers Baseball Game, Farma Family Campground (Swimming, Fishing, Putt Putt) and a celebration of Mercer County K.I.D.S. Day, at the Mercer County Courthouse.
• Parents are invited on all fieldtrips!
• Campers will receive a calendar of events for Mercer County K.I.D.S. camp (during registration or first day of camp) and a copy of the rules and regulations for each child attending camp.
• Campers will complete two tests: A Pre and Post Knowledge Test at the beginning and end of camp and a Decision Making Survey, in summer 2015 and spring 2016.
• Campers are invited to participate in 3 Mercer County K.I.D.S. Club Meetings between September 2015 and May 2016.
• The final Camp K.I.D.S. club meeting in spring 2016 will be a Year-End Celebration and a 6th grade CAMP KIDS Graduation Celebration.
Parent/Guardian Signature: ______________________________________________Date______________
TURN OVER
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