<p> Parental Permission </p><p>I______, authorize my child,______to Please Print Parent Name Please Print Child Name attend the upcoming Safety Camp offered by Christopher's Clubhouse.</p><p>My signature below hereby acknowledges to Christopher's Clubhouse and its Instructor or Instructors:</p><p>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.</p><p>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.</p><p>I HAVE READ THE ABOVE WAIVER AND RELEASE, AND I SIGN IT VOLUNTARILY.</p><p>Signature______Date______(Parent or Legal Guardian)</p><p>Telephone #______Email: ______</p><p>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</p><p>Child's Name:______(First) ( Middle) (Last)</p><p>Nick Name:______Parent/Guardian Name:______</p><p>Gender: Male ____ Female____ Child's Height:______Weight: ______</p><p>Eye Color: ______Hair Color: ______Glasses: Yes/No Race: ______</p><p>Date of Birth: ______Distinguishing Marks: ______</p><p>Other Health Considerations: ______</p><p>Primary Phone Number: ______</p><p>Address: ______</p><p>City:______State: ______Zip: ______</p><p>Does your child have any ongoing medical conditions that would be of concern for participation: ______Yes ______No</p><p>If yes, please explain: ______</p><p>______</p><p>Is your child currently taking any prescription medication? ______Yes ______No</p><p>If Yes, please list: ______</p><p>Does your child have: Any known allergies Yes ______No ______Difficulty breathing Yes ______No ______High blood pressure Yes ______No ______Diabetes Yes ______No ______</p><p>The above information is complete, true and accurate to the best of my knowledge.</p><p>______Parent Signature </p>