Student Information:
铁道警察学院分数线Student’s Name: _______________________________________________________ Church or Group:_______________________________________________________ Date of Birth: _________ Age: _______ Gender: Male Female
E-mail:______________________________ Cell Phone:(_____)______-_________ Mailing Address: ____________________________________昆明陆军讲武堂
____________________________________
____________________________________
Parent / Guardian Information:
Parent / Guardian Name(s): ______________________________________________ Day Phone: (_____)______-_________ Evening Phone: (_____)______-_________ Cell Phone 1: (_____)______-_________ Cell Phone 2: (_____)______-_________ Parent / Guardian E-mail:_________________________________________ Emergency Contact Person: ______________________________________ Relationship: ___________________________________________________
Day Phone: (_____)______-_________ Evening Phone: (_____)______-_________ Cell Phone: (_____)______-_________
Medical & Insurance Information:
Medical History: (Plea check items applying to camper.)
Hay Fever Bronchitis Asthma Fainting Spells
Ear Trouble
军号声Heart trouble装修开工仪式吉利话
Diabetes
Convulsions
Tetanus Booster, date ________Seriously allergic to Poison Ivy, Oak or Sumac Other ____________________________________________________________
Allergic Reactions: Bee stings Penicillin Peanuts Other _________________
Plea list any over-the-counter medications camper is not allowed to have:
______________________________________________________________________ Dietary Restrictions:
______________________________________________________________________ Other medical concerns (attach explanation):
______________________________________________________________________
List prescription medications camper will bring. Include instructions signed by parent:
______________________________________________________________________ Insurance Company and Policy Number (photocopy of insurance card is helpful):
______________________________________________________________________
If you wish to limit your child from any normal camp activities due to medical reasons,
赋字笔顺plea list & explain:
______________________________________________________________________
数列练习题Wayumi camper registration form – Page 1 of 2
Student’s Name: ____________________________________________________
MEDICAL RELEASE
Must be completed for all students 18 years of age and under!
In ca of emergency, I understand that every effort will be made to contact me. I hereby give my permission to the physician chon by New Tribes Mission’s staff to hospitalize and/or cure proper treatment for, and order injections, or anesthesia, or surgery for my child as named on this form. I certify that the child named on this form has my permission to attend the Wayumi program. Also, for
promotional purpos only, New Tribes Mission has my permission to u pictures or videos that should happen to include my child.
___________________________________________________ _______________ Signature of Parent / Guardian Date
RELEASE OF LIABILITY
Although New Tribes Mission desires to provide a safe and enjoyable time for all persons that come onto its property and make u of its facilities, I/we understand that there are risks/dangers involved with participation in such associated activities. Some risks that may result in participating could include but not be limited to: pain or bruising, possible injury from sliding or falling, sprains or injury from running over uneven ground, possible eye, no or ear injury. In consideration of my/our child being allowed to participate in such events at the property of New Tribes Mission, I/we assume the entire responsibility and liability for any and all injury of any kind or nature, whatever and assume reasonable risks associated with such activities. I/we agree to hold harmless New Tribes Mission, its affiliated organizations, employees, agents, and reprentatives, from any and all claims arising from my/our child’s participation.
I/we agree to indemnify and save harmless New Tribes Mission, its officers, agents and employees from any and all such claims, loss, expen, legal fees, that New Tribes Mission may suffer or sustain as a result of any claim that might be made against it and I/we do further hereby assume the defen of any action at law or in equity which may be brought against New Tribes Mission as a result of my/our child’s participation. Also, for promotional purpos, NTM has my permission to u pictures or videos that happen to include my child.
DATED this _____ day of _______________________, _______.
_______________________________ __________________________________ Name of Student Signature of Parent冷冬
_______________________________ __________________________________ Witness Witness
珍爱生命的作文Wayumi camper registration form – Page 2 of 2
