HARMONY IN THE STREETS CAMP
REGISTRATION AND RELEASE FORM
ALL BLANKS & QUESTIONS MUST BE COM PLETED FOR THE CAMPER TO ATTEND CAMP. PLEASE PRINT LEGIBLY
CAMPER LAST NAME 	CAMPER FIRST NAME----- ----

DATE OF BIRTH 	_

ADDRESS 		- - - - - - - - - - - - - - - - - - - -
CITY 	STATE 	ZIP 	

DAYTIME PHONE 	EVENING PHONE 	_

PARENT/GUARDIAN NAME--------------------------
EMERGENCY CONTACTS: (MUST BE COMPLETED FOR CAMPER TO ATTEND CAMP)
NAME: 	PHONE: 	_

NAME: 	PHONE:  	

EMAIL  ADDRESS:  	

Camper will be picked up by: 	_

As the parent(s)/guardian(s) of  	,I/we hereby agree:

To the extent authorized by and subject to the limitations specified in Section 768.28, Florida Statue, the parents of 	_ agrees to indemnify and hold harmless, the Palm Beach County Sheriff's and staff, their agents, employees, designees and independent contractors and volunteers from any and all manner of action and actions, caused and causes of actions, suits, damages, judgment and claim of any kind whatsoever, in law or in equity, by its employees or third parties which are based in whole or in part upon injuries or damages sustained by its employees it by third parties which are direct or indirect result of my child being involved in the Harmony in the Streets Summer Camp program.
To give permission to participate In approved camp activities as well as off-site field trips, except restricted by doctor's orders.
To give the agencies permission to photograph and allow photos to be used for news and media releases and for programs development which may include presentations/participation at various community, district or state conferences.
To give the agencies complete authority in regards to discipline matters, authority to make decision regarding medical problems plans for treatment and the ability to transport when necessary.
To give the Florida Sheriffs Youth Ranches, Inc. permissi on to transport my child and release the Florida Sheriffs Youth Ranches, Inc. and private parties providing Camp transportation from all liability.

Is your child being treated for any of the following:

Diabet esO Yes e No Asthma 0 Yes G) No

Hemophilia or bleeding disorder0 YesGNo
Epilepsy or SeizuresO Yes G No

Other (please list) 	_

bIs your child currently taking medicat ion? OVes  Gl) No
Prescription Medication 		_ Non-prescription Medication 	_
*All medication must be in original pharmacy container/bottle and labeled with appropriate medication label. Times for administration must be noted.

c. Does your child have aller gies?Gl)Yes O No

Parent/Guardian Signature -------------------------------