SA Camp Registration - West Texas Rehab

I understand that Camp Rehab is currently full, and I am joining the waitlist. I will be contacted if an opening becomes available.

Yes, I Understand

Camper Information

Campers Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male
Female

Campers Age

Shirt Size

Swimming - My child has permission to get into a swimming pool under supervision and with a life preserver

Campers Diagnosis

participation activities Size

Campers Physician

Does the Child need any Medication? If so please list medication dosage and time taken below. (Medication will be given to the nurse each morning of camp with instructions, and should be picked up from nurse each day at the end of camp)

Allergies (food, plants, medications, etc.)

Special instructions (including equipment needs)

Guardian Information

Parent or Guardian Name

First

Last

Phone

Email

I would like to add an additional emergency contact.

Consent Forms

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by West Texas Rehab Center during the selected camp. In exchange for the acceptance of said child’s candidacy by West Texas Rehab Center . I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless West Texas Rehab Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against West Texas Rehab Center . including all affiliates, all participants and, if applicable, owners and lessors of premises used to conduct the event.

I hereby grant to West Texas Rehabilitation Center, their agents, successors, assignees, and affiliates, and their respective employees, officers, directors, board members, and representatives (collectively “Producers”) the right and permission to film, photograph, and record me, transcribe the recording, and to use my name, voice, image, information about me and any ideas or materials that I provide Producers (collectively, the “Materials”) in works created by Producers (the “Program”) and in connection with advertising, publicizing, broadcasting, producing, and exploiting the Program, in any and all media and mediums now known hereafter developed, in perpetuity. I understand that Producers are under no obligation to incorporate my appearance in the Program. Producer may edit and Video as it sees fit, and may resnlate the Material into languages other than English.

Signature

Clear Signature