Parental Permission

I______, authorize my child,______to Please Print Parent Name Please Print Child Name attend the upcoming Safety Camp offered by Christopher's Clubhouse.

My signature below hereby acknowledges to Christopher's Clubhouse and its Instructor or Instructors:

That my son/daughter and I are aware of the physical nature of this course. That he/she is physically fit to participate in this course, involving various physical techniques; and, we realize that such techniques cannot be successfully employed in every situation, and proficiency can only be achieved through continued practice, exercise of good judgment, and a person’s natural ability. I also understand that sensitive subject matter will be discussed including safe and unsafe touch and I am aware that Parents are strongly suggested to attend all sessions with their child and participate as able.

My signature also releases Christopher's Clubhouse Instructor or Instructors, and sponsor, and agrees to hold them harmless, from any liability for injury that may be incurred as a result of this course, or use of the strategies within.

I HAVE READ THE ABOVE WAIVER AND RELEASE, AND I SIGN IT VOLUNTARILY.

Signature______Date______(Parent or Legal Guardian)

Telephone #______Email: ______

The initializing of this box also grants permission for my child’s picture to be taken for the purpose of the graduation certificate and/or general media or press release from Christopher's Clubhouse. Registration Form

Child's Name:______(First) ( Middle) (Last)

Nick Name:______Parent/Guardian Name:______

Gender: Male ____ Female____ Child's Height:______Weight: ______

Eye Color: ______Hair Color: ______Glasses: Yes/No Race: ______

Date of Birth: ______Distinguishing Marks: ______

Other Health Considerations: ______

Primary Phone Number: ______

Address: ______

City:______State: ______Zip: ______

Does your child have any ongoing medical conditions that would be of concern for participation: ______Yes ______No

If yes, please explain: ______

______

Is your child currently taking any prescription medication? ______Yes ______No

If Yes, please list: ______

Does your child have: Any known allergies Yes ______No ______Difficulty breathing Yes ______No ______High blood pressure Yes ______No ______Diabetes Yes ______No ______

The above information is complete, true and accurate to the best of my knowledge.

______Parent Signature