The staff of Camp Fiesta has my permission to release my child,____________________at any time during the camp day to any of the following persons:
Name Relationship to the child
_______________________________________ ______________
Signature of parent Date
Please note: The Camp Director must be notified in advance if anyone not listed above is to be allowed to pick up your child. That individual, if not known to the camp staff, will be required to produce identification satisfactory to the staff. If no notification has been given in advance, we will attempt to contact you and will not allow your child to leave until we do.
Thank you for your cooperation.
Carina Giusti MS
Camp Director
Emergency Consent Form
In the event of an emergency and I cannot be reached, I hereby give permission for the Spanish Fiesta Summer Camp (SFSC) Director or their staff to obtain treatment for my child. I hereby authorize any health care provider to rely on this consent for treatment for my child. I give permission for treatment provided by EMTs and by staff trained in first aid.
I give permission and understand that SFSC Director or their staff, or emergency services will provide transportation to the nearest Hospital. I agree to hold harmless, Spanish Fiesta Summer Camp, Director and staff, against and from all liabilities, claims, costs, charges, and the like, due to any injury to my child, and/or treatment arising from my child's participation.
SIGNED____________________________ DATE________________
Parent's Siganature
Other important information we need to have
Emergency contact other that parents:
Name and relationship:______________________________________
Daytime Ph: ___________________ Cell Ph:_____________________
Pediatrician name & phone ___________________________________
Allergies: Yes No
Please list all:_____________________________________________
Degree of severity Mild 1 2 3 4 5 6 7 8 9 10 Critical
(circle one)
Special remedies required: (ie Epi-pen) _________________________
* Please list any special needs your child may have and make us aware of any medications your child takes and/or may need during the camp day
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Late pick up fee information
I_______________________________________(parent printed name), agree and understand that Spanish Fiesta Summer Camp, will begin at 8:00am and will end at 12 noon. A late pick up fee in the amount of $1 per minutes will be imposed for each child leaving camp after 12 noon.
___________________________ ____________________
Parent's signature Date
