Child “Camper” Information Form
City of Mercer Island Parks and Recreation Department
Please complete this form prior to the first day of camp and mail to 2040 84th Ave SE
Mercer Island, WA 98040. Or email form to miparks.net
One form per child okay as long as all classes/ camps are listed.
Camper Information (please print or type).
Class/Camp
(list all):
Child’s Name:
D.O.B/Age/Gender
Address/City/State:
Telephone: (home)
Mobile phone:
Mother’s Name:
Employer & Phone
Father’s Name:
Employer & Phone
Alternate Legal
Guardian:
Address/Phone
Emergency Contacts
Name:
Phone & Relationship
Name:
Phone & Relationship
Physician Information
Child’s Physician:
Phone
Medical Insurance
Company:
Medical Information
Please list Child's medical history/cautions, medical/special needs (medication, allergies, physical or
mental disability, behavior disorders, attention disorders, others):
Authorized Alternate Child Pick-up (list all including parent(s) authorized to pick up)
Name
Address/Phone
Relationship
-See Reverse Side-
Please list any persons including parent(s) who are not authorized to pick up your child.
A court order must be on file in order to authorize the enforcement of this restriction.
Name
Address/Phone
Relationship
INSURANCE
It is the responsibility of every individual, their parent or legal guardian to provide for their own accident and health
coverage while participating in all City of Mercer Island Recreational activities
PHOTOGRAPHY, VIDEO AND PROMOTIONAL RELEASE
I do hereby authorized and Release the City of Mercer Island to take and use photographs, video and written comments of
or by my child for promotional and informational materials. Further I agree to release and discharge the City of Mercer
Island from any and all liability in connection with the use of such photographs, video and written comments of or by my
child.
AUTHORIZATION
Part