Authorization Form

A completed form for each camper is required. If a camper is attending multiple weeks, only one authorization form is necessary.
If you are enrolling multiple campers, click here to complete an additional form.

Camper Name*
First Last
Camper Birthdate
MM slash DD slash YYYY
Camper Grade in Fall
Parent 1 Name*
First Last
Parent 1 Cell Phone*
If you don't have a cell phone, enter home phone.
Parent 1 Work or Daytime Phone
Parent 1 Email*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent 2 Name
First Last
Parent 2 Email
Parent 2 Cell Phone
If you don't have a cell phone, enter home phone.
Parent 2 Work or Daytime Phone
Emergency Contact*
If neither of the above can be contacted, in the case of an emergency call:
Name Phone Number
Physician*
To be called in an emergency.
Name Phone Number
Insurance
Provider Policy Number
Allergies, physical or medical limitations*
If none, write "none".
Persons authorized to take child from camp
Persons authorized to take child from camp (child will not be allowed to leave with any other person without authorization from parent or guardian):
Name
First Last
Relationship
Name
First Last
Relationship
Name
First Last
Relationship
Indemnification, Waiver, and Release
Indemnification, Waiver and Release: In consideration for my, or my child’s participation in a Summer Arts Class, taught by Kalen Meyer, I agree to: 1. Assume all risk of injury to my child and all risk of damage to or loss of property arising out of my own or my child’s participation in this program. 2. Release, discharge and waive any and all responsibility of Kalen Meyer or Berkwood Hedge School, 1809 Bancroft Ave., from and against liability for any injury, including death, and for damage to or loss of property which may be suffered by my child or myself arising out of, or in any way connected with participation in this program. 3. Indemnify and hold harmless Kalen Meyer or Berkwood Hedge School, 1809 Bancroft Ave., from and against all liability, claims, demands, actions, loss and damage arising out of my child’s participation in said program.
Authorization of Consent to Treatment of a minor:
The undersigned, as parent or legal guardian of this minor, hereby authorizes Kalen Meyer to consent to any emergency medical or hospital care to be rendered to said minor upon the advice of a licensed physician. It is understood that if time and circumstances reasonably permit, Kalen Meyer will endeavor, but is not required, to communicate with the undersigned prior to such treatment. The undersigned further agrees that Kalen Meyer is not legally or financially liable for any claim arising from any consent given in good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment of a minor is given to Kalen Meyer and shall remain effective until August 31, 2021.
Consent*
I agree to the above conditions of attending camp.
Name*
First Last
Date*
MM slash DD slash YYYY

Persons authorized to take child from camp

Indemnification, Waiver, and Release

Authorization of Consent to Treatment of a minor: