LANTERN SUMMER CAMPSREGISTRATION INFORMATION

____________________________________STUDENT INFORMATION

Student Name ____________________________ DOB ________ Primary Care Doctor’s Name____________________________

Doctor’s Contact Number _______________________ Insurance (circle) Yes No Provider ___________________________________

Medical Plan Type __________________________ Group Number ____________________ Member Number ___________________

Medical conditions ___________________________________ Medications __________________________________________________

Allergies ___________________________________________ Treatment/Medications _________________________________________

Medical History/Surgeries/Treatments ___________________________________________________________________________________

EMERGENCY CONTACT

Name ___________________________________ Phone _____________________ Relationship _______________________

Name ___________________________________ Phone _____________________ Relationship _______________________

The undersigned gives permission to Lantern, its owners and operators to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I request that our doctor/physician be called and that my child be transported to the nearest hospital.

___________________________________ ______________________________________ ________________________Parent or Guardian Name Parent or Guardian Signature Date

Injury and Image Waiver: The student, the parent, or the legal guardian on behalf of the student, acknowledges and is fully cognizant of all the inherent liabilities in connection with the execution of a martial art and acknowledges that the execution of a martial art requires physical exertion and contact, and realizes that there is a risk of physical injury which may be incurred while engaged in this activity. The student, parent, or legal guardian on behalf of the student, hereby waives any and all claims for any physical injury in connection with the training at Lantern and expressly assumes the risk of all dangers or injury inherent to martial arts. The student, parent, or legal guardian on behalf of the student further acknowledges and gives consent for Lantern to use any and all images of the student acquired in the course of participation in martial arts without compensation or remuneration.

I, the student, or the parent on behalf of the student declares that the above information is true and correct to the best of my knowledge, and I acknowledge receiving a copy of this agreement.

__________________________ ________________________ ______________________ Student or Parent or Guardian Name Student or Parent or Guardian Signature Date

(For Office Staff Only)

Full Day or Half Day Before Care After Care Registration Fee Camp Fee

Notes: