Camp Medical Forms – Cedar Falls Dance Team

Forms must be completed by NOON on Thursday, July 15th.

This medical release form must be completely filled out be every attendee participating an MA / Marching Auxiliaries summer camp. Make copies as needed - every participant, adult & minor, must complete a separate form.

Participant Name(Required)

First Last

Name of Parent or Guardian 1

First Last

Name of Parent or Guardian 2

First Last

Optional

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell(Required)

Email(Required)

Physician Information

Name of Physician(Required)

First Last

Physician phone number(Required)

Is the participant allergic to any medication?(Required)

Yes

Please list.(Required)

Other Medical information that physician may need to know in case of emergency

Name of insurance carrier(Required)

Policy Number(Required)

Phone number for insurance company(Required)

Photo/Video Release Form

Consent(Required)

I agree to the Photo/Video Release

I grant to Marching Auxiliaries, Inc., its representatives, and employees the right to take photographs /video footage of me and my property in connection with this event. I authorize Marching Auxiliaries, Inc., its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I agree that Marching Auxiliaries, Inc., may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

I grant Marching Auxiliaries, Inc. the right to photograph/video my child during this event and post on the company website.

Your signature constitutes full acceptance of all conditions expressed in this release form. I have read and understood the above:

Digital Signature(Required)

Todya's Date(Required)

School Group(Required)

Enter Cedar Falls High School