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C.A.C. Emergency Form

2. 1st Participant Information

4. First Name*

5. Last Name*

7. Preferred Name

8. Date of Birth*
   Date of Birth

9. Age of Child*
   -- Select One --56789101112131415

   Child must be 5 years old by the first day of camp.

11. Health Conditions, Allergies, Physical Restrictions, Behavior Plan, Medications

13. See below for descriptions and please mark Yes or No for each:

15. Permission to Record & Photograph Child Participating in Activities*

    1. Yes

    1. No

17. Waiver of Liability & Permission for Medical Consent*

    1. Yes

    1. No

19. Permission to Administer Questionnaires to Participants*

    1. Yes

    1. No

23. 2nd Participant Information

25. First Name

26. Last Name

28. Preferred Name

29. Date of Birth
    Date of Birth

30. Age of Child
    -- Select One --56789101112131415

    Child must be 5 years old by the first day of camp.

32. Health Conditions, Allergies, Physical Restrictions, Behavior Plan, Medications

34. See below for descriptions and please mark Yes or No for each:

36. Permission to Record & Photograph Child Participating in Activities

    1. Yes

    1. No

38. Waiver of Liability & Permission for Medical Consent

    1. Yes

    1. No

40. Permission to Administer Questionnaires to Participants

    1. Yes

    1. No

44. Parent(s)/Guardian(s) Name(s):*

46. Address1*

48. Address2

50. City*

51. State*

52. Zip*

54. Email Address*

58. Emergency Contact 1 - Name*

59. Emergency Contact 1 - Phone #:*

61. Emergency Contact 2 - Name*

62. Emergency Contact 2 - Phone #*

64. Emergency Contact 3 - Name*

65. Emergency Contact 3 - Phone #*

69. Signing In & Out*

    I understand that my child needs to be dropped off and picked up by an adult listed on this emergency contact form. I understand that my child is unable to walk home alone unless special arrangements have been made with a CAC Coordinator by calling734/394-5430.

    1. Yes
    2. No
71. Permission to Record & Photograph Child Participating in Activities*

    I hereby release to Canton Township rights to my child’s image, likeness, and the sound of his/her voice as recorded or photographed. I understand this recording or photograph may be edited and placed in publications, and thereafter the recording or photograph may be otherwise available. I agree to release, discharge, and save harmless Canton Township, including its representatives or designees, from any legal proceedings which may arise in relation to the conditions of the above paragraph.

    1. Yes
    2. No
73. Permission to Administer Questionnaires to Participants*

    I hereby give Canton Township my permission to administer questionnaires to my child for the purposes of improving future programs. I understand that the information collected from my child will remain anonymous and that my child’s identity will not be revealed in relationship to the survey.

    1. Yes
    2. No
75. Waiver of Liability & Permission for Medical Consent*

    In consideration of Canton Township permitting my child to participate in and providing transportation to and from said events, I hereby for myself, my child, my heirs, administration and assigns, waive & release any and all rights and claims for damages I may have against Canton Township, its personnel and any other organizations connected with this event, their successors, and assigns for any and all injuries which my child may suffer while taking part in any activities connected with this event. In case of injury, and I am unable to be contacted by your staff, I give my consent to have medical treatment administered to my child if deemed necessary by a physician.

    1. Yes
    2. No
77. Parent/Guardian Signature*

    Type Name for Signature

78. Date*
    Date

80. By checking "yes", I certify that the information contained in this application is accurate. I agree:*

    1. Yes
    2. No

82. I understand that checking this box constitutes a legal signature confirming that I acknowledge that I am the signer, and further that I agree to the above Terms of Acceptance. *

    1. Yes
    2. No

Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field