Participant Waiver Form

Acceptance of Health Service Emergency Treatment

Child's Name *

Child's Age *

If my child should become ill or injured during camp, I DO HEREBY GIVE MY PERMISSION for my child to receive all necessary medical attention if the need arises, including permission for my child to be transported to and seen and/or treated by the nearest hospital in the vicinity of the event. Need shall be determined solely at the discretion of the emergency medical provider and/or the professional staff supervising or coordinating the activity, trip or event.

SIGNATURE OF PARENT/GUARDIAN *

clear

RELATIONSHIP TO CHILD *

DATE (MM/DD/YYYY) *

Participant Must Have Medical Insurance

Name of Insurance Company *

Group Number *

Policy Number *

Name of Policy Holder *

Relationship to Participant *

Photo Release

I authorize Baldwin Wallace University to use photographs of my child and his/her work for promotional purposes which may include Baldwin Wallace University online and print publications or submission to the press for use in articles or advertisements. *

Yes

PARENT/GUARDIAN SIGNATURE *

clear

DATE (MM/DD/YYYY) *