Camp Ray of Hope Registration - New Hope for Kids

Child 1 Name
First Last
Age
- Male
- Female
Physician's Name
Phone
Date of Last Immunizations
MM slash DD slash YYYY
Health Insurance Company
Policy #
Please list any medical conditions that your child has
Please list any allergies including reaction & treatment (drugs, food, environment, bites, etc.)
Please specify any dietary restrictions
Other medical conditions that may affect any camper's activities while at camp

Child 2 Name
First Last
Age
- Male
- Female
Physician's Name
Phone
Date of Last Immunizations
MM slash DD slash YYYY
Health Insurance Company
Policy #
Please list any medical conditions that your child has
Please list any allergies including reaction & treatment (drugs, food, environment, bites, etc.)
Please specify any dietary restrictions
Other medical conditions that may affect any camper's activities while at camp

Child 3 Name
First Last
Age
- Male
- Female
Physician's Name
Phone
Date of Last Immunizations
MM slash DD slash YYYY
Health Insurance Company
Policy #
Please list any medical conditions that your child has
Please list any allergies including reaction & treatment (drugs, food, environment, bites, etc.)
Please specify any dietary restrictions
Other medical conditions that may affect any camper's activities while at camp

Child 4 Name
First Last
Age
- Male
- Female
Physician's Name
Phone
Date of Last Immunizations
MM slash DD slash YYYY
Health Insurance Company
Policy #
Please list any medical conditions that your child has
Please list any allergies including reaction & treatment (drugs, food, environment, bites, etc.)
Please specify any dietary restrictions
Other medical conditions that may affect any camper's activities while at camp

AUTHORIZATION TO USE WRITTEN MATERIALS / PHOTOGRAPHS / VIDEO
i hereby authorize New Hope for Kids and any project sponsor affiliated with New Hope for Kids to use, reproduce, and/or publish all written and/or visual materials, including photographs and artwork that may pertain to me, my family, and any minor children. I understand that this material may be used in various publications, public affairs releases, recruitment materials, or for other related endeavors. This material may also appear on New Hope for Kids Internet Web Page. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, New Hope for Kids and/or project sponsor may publish materials, use my name, first name only of any minor children, photograph, and/or make reference to me in any manner that New Hope for Kids or project sponsor deems appropriate in order to promote/publicize service opportunities.
Date
MM slash DD slash YYYY