Summer Impact Health Form Summer Impact Student Name First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact First Name Last Name Relationship of Emergency Contact * Emergency Phone * (###) ### #### 2nd Emergency Contact * First Name Last Name Relation to 2nd Emergency Contact * 2nd Emergency Contact Phone (###) ### #### Medical Insurance Provider * Policy Number * Medical Waiver * Medical Waiver By electronically signing this document below, I hereby verify that the below information is complete and accurate to my knowledge. I hereby grant permission to receive first aid and emergency treatment by JumpIn NW Program personnel in the event of injury, or by the hospital emergency room, for a life-saving decision if emergency contacts cannot immediately be reached. I voluntarily waive any claim against JumpIn NW personnel, or other persons transporting me, against all liability, claims, damages, attorney fees, or expenses arising out of or in connection with any activities of the above-mentioned organization. Photography Release * Photography Release * If I am in a photograph taken by Jump-In NW designated staff the photograph may be used in publications on-line or in print for advertising purposes.. Jump-In NW will not include the name of our staff on any publications or sell merchandise with your photo. Jump-In NW will not share your photo with any business. It is for the exclusive use of Jump-In NW Camp publications and advertising. Photos of me may be included in Jump-In NW publications. I do not want to have photos taken by Jump-in NW used in publications. Is Tetanus Shot Current? * YES NO Date of Last Known Tetanus MM DD YYYY List any Allergies and your reaction to that Allergy Medications you need at camp This will be confidential and only known by Sr. Staff. You will administer the medications yourself and keep them in your room away from campers. If an emergency does arise it may be helpful to know what medications you are taking. Thank you!
