Reid Park Zoo Waiver Form Health, Emergency Contact and Waiver of Liability Form- SUMMER This must be filled out by the parent/guardian of any camp participant AFTER you have registered for camp. AOL AND YAHOO EMAIL USERS - Please note that this form may not send correctly from these accounts. Please call 837-8090 to confirm we have received your form if using an AOL or YAHOO email. Thank you! Health, Emergency Contact and Waiver of Liability Form - Summer CampCamp Participant's Name* First Last Camper's GenderCamper's AgeCamper's Race/Ethnicity (optional)This information is used to understand Reid Park Zoo's diversity within the summer camp program and to assist in obtaining future grants for camp scholarships.Grade Your Camper will Enter in the Fall*Grade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Week Participant Will Attend CampJune 3-7June 10-14June 17-21June 24-28July 8-12July 15-19July 22-26July 29-Aug 2Days Participant Will Attend CampJune 10-12July 1-3July 29-31Please share any medical, physical, cognitive, or behavioral conditions which would be important for instructors to knowWe encourage your camper to bring any sensory tools of their own that would help them have a positive camp experience. Please list those items above so camp staff is aware. Reid Park Zoo has sensory tools available for camper use, please call 837-8200 to learn more. Zoo camp is fun and exciting, and can at times lead to heightened emotions. Please tell us how to best support or comfort your camper if neededPlease describe any restrictions of activity or dietPrimary Adult Contact's Name* First Last Relationship to Participant*Primary Phone*Secondary PhoneIs the Participant free of infectious disease, up to date on all immunizations required to attend school, and able to participate in recreation activities (with the limitations/restrictions listed above)?* Yes No Is the participant taking medication?* Yes No Name of medication(s)Will medication(s) be taken during program hours?* Yes No Medication PermitThe following information relates to your responsibilities if your child requires medication(s): 1.) For each medication required, a Medication Permit must be filled out and signed. Staff will not administer any medication that does not have a signed permit, including non-prescription medications. NO invasive medical procedures will be administered. 2.) All prescription medications must come in a pharmacy bottle with a legible pharmacy label on it. The label must contain the participant’s name, the pharmacy’s phone number, the name of the medication, dose and frequency required, and the doctor’s name. 3.) All non-prescription medications must be submitted in the original sealed container with the participant’s name, dose, and frequency clearly labeled on the container. Name of Medication*Dosage*Name of Doctor Prescribing Medication*Instructions for Giving Medication*Possible Side Effects*By initialing below, I hereby authorize Zoo Summer Camp Staff to give the above named medication to my child.*Emergency ContactsContact's Name* First Last Please provide 2 emergency contactsRelationship to Participant*Primary Phone*Secondary PhoneContact's Name First Last Relationship to ParticipantPrimary PhoneSecondary PhonePlease list any other individuals who are authorized to pick up participant (individuals will be required to show a photo ID when picking the participant up). ONLY ADULTS LISTED BELOW, PRIMARY AND EMERGENCY CONTACTS WILL BE ABLE TO PICK UP YOUR CAMPER. PermissionsI understand that 911 may be called in the case of a medical emergency* Yes I do I hereby grant Reid Park Zoo permission to record the participant’s likeness and/or voice for use in television, social media, radio, or printed materials to further the aims of the Zoo in related campaigns and in other ways they may see fit.* Yes I do No I do not By entering my initials below, I release and hold harmless the Reid Park Zoo, Reid Park Zoological Society, the City of Tucson, and employees or agents thereof, from any and all claims, liabilities, or demands whatsoever arising out of the enrollment or participation in any program by the participant herein.*Relationship to Participant*Date* Date Format: MM slash DD slash YYYY