History Camp Registration Form // Events // The Castle

In the event of an emergency, The Castle contacts emergency services, and then the primary and secondary contacts listed on this form. This form will be provided to emergency service personnel.

Emergency Medical Authorization

Camper’s Name *

Primary Emergency Contact Name *

Primary Contact Home Phone

Primary Contact Cell Phone *

Primary Contact Work Phone

Secondary Emergency Contact Name *

Secondary Contact Home Phone

Secondary Cell Phone *

Secondary Work Phone

Medical History

Allergies (Food, Pollen, etc.) *

Food Preferences (Vegetarian, Vegan, Etc.)

Medications Being Taken: *

Tell us a little about your camper

My camper uses a wheelchair, crutches, walker or another mobility aid My camper might be sensory sensitive My camper has vision loss My camper is deaf or hard-of-hearing My camper has an intellectual disability

Please elaborate on any boxes marked

Is there anything else you wish for us to know about your camper?

Part I: To Grant Consent
I hereby give consent for the following medical care providers and local hospital to be called:

Doctor *

Doctor’s Phone *

Dentist *

Dentist’s Phone *

Medical Specialist

Medical Specialist’s Phone

Hospital

Hospital’s Phone

Can we administrator first aid? *

Yes No

In the event, reasonable attempts to contact emergency contacts have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctor, or in the event that the designated practitioner is not available, by another licensed physician or dentist, and (2) the transfer of the camper to any hospital reasonably accessible.

Date

Signature of Parent or Guardian

Please type your first and last name

I understand that checking this box constitutes a legal signature

Part II: Refusal to Consent

I do NOT give my consent for emergency medical treatment of my camper. In the event of illness or injury requiring emergency treatment, I wish The Castle authorities to take the following action:

Medical Instructions

Date

Signature of Parent or Guardian

Please type your first and last name

I understand that checking this box constitutes a legal signature

Permission to use Photograph

History Camp 2022

Camper(s)’s Name(s)

I grant to The Castle, its representatives and employees the right to take photographs of my camper in connection with the above-identified event. I agree that The Castle may use such photographs of my camper with or without their name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, web content, and social media. I do NOT grant to The Castle, its representatives and employees the right to take photographs of my camper in connection with the above-identified event.

Date

Parent/Guardian Signature

Please type your first and last name

I understand that checking this box constitutes a legal signature

Phone Number

Click the Submit button above to complete registration.

Registration and payment must be received together to ensure a spot in camp.

The Castle's History Camp: A New Age 1900 – 1920 (July 11-15, 2022 9am-3pm)

History Camp Guidelines