Authorization Form A completed form for each camper is required. If a camper is attending multiple weeks, only one authorization form is necessary. "*" indicates required fields Camper Name* First Last Camper Birthdate MM slash DD slash YYYY Camper Grade in FallParent 1 Name* First Last Parent 1 Cell Phone*If you don't have a cell phone, enter home phone.Parent 1 Work or Daytime PhoneParent 1 Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Parent 2 Name First Last Parent 2 Email Parent 2 Cell PhoneIf you don't have a cell phone, enter home phone.Parent 2 Work or Daytime PhoneEmergency 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 campPersons 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 RelationshipParent of another camperAunt, Uncle or GranparentFriendSibling 14 or overName First Last RelationshipParent of another camperAunt, Uncle or GranparentFriendSibling 14 or overName First Last RelationshipParent of another camperAunt, Uncle or GranparentFriendSibling 14 or overIndemnification, Waiver, and ReleaseIndemnification, 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
