Peace Wars 2017

The undersigned, being a parent or legal guardian of the child requesting camp admittance, does hereby affirm that the applicant is in good health and suffers from no illnesses, disabilities or condition that requires the taking of medication on a regular basis unless that condition is disclosed on the registration form and approved for participation. Furthermore, the undersigned has no knowledge of any reason the applicant cannot participate in vigorous physical activity. The undersigned hereby expressly agrees to be responsible for any medical bills incurred in the treatment of any illness or accident. In the event of any such accident or injury, I hereby consent to allowing any camp supervisors or procure any medical treatment deemed advisable on behalf of my child or ward without prior consent recognizing that no entity involved with the Norris Cole Foundation, Dayton Public Schools or the City of Dayton assumes responsibility for, nor do they have any liability for, the medical care selected or provided. No primary care medical insurance is provided by Norris Cole Foundation, Dayton Public Schools or the City of Dayton or any other entity involved with Peace Wars. I understand that as an admission as a camper, the undersigned, on behalf of all parents and guardians, and on behalf of the applicant, hereby releases the Norris Cole Foundation, Dayton Public Schools or the City of Dayton and any other entity associated with the camp and all other employees, volunteers, vendors, sponsors or agents of the camp from any and all liability from injury or illness, mental or physical, suffered by the camper during or related to camp activities including being photographed, unless caused by willful act or gross negligence by the person or entity against whom the claim is made.

Peace War events are free and open to the public. Completed forms can be mailed to 893 S. Main Street #355 Englewood Oh 45322or emailed to info@norriscolefoundation.org.Participants are encouraged to register prior to the day of the event. Onsite registration available, but space is limited. For additional information call (937) 265­8681.

Participant *
Participant
Phone *
Phone
Address
Address
DOB *
DOB
Please provide any and add all medical conditions - medications - allergies
Name of Emergency Contact 1 *
Name of Emergency Contact 1
Cell Phone *
Cell Phone
Name of Emergency Contact 2 *
Name of Emergency Contact 2
Cell Phone *
Cell Phone
Parent/Guardian E-Signature
Parent/Guardian E-Signature