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Hindu Swayamsevak Sangh
Hindu Heritage Camp - 2004
Registration Form
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Please fill out separate form for each child.
Child's First Name:
Last Name:
Date of Birth (mm/dd/yyyy) :
Mother's Name:Father's Name:
Phone (Home): Phone (Office):
Phone (Emergency):Email:
Street Address:
City:State:Zip:
Comments:
Medical Insurance: Medical Insurance Company Name:
Group #: Subscriber #:
Personal Physician's name:Physician's phone:
Parent's Consent
- I hereby release Hindu Swayamsevak Sangh and its officers of any liability for any accidents or injuries my child may incur while attending the Camp.
- I and my health insurance company are completely responsible for the payment of all expenses incurred for any kind of medical and/or surgical treatment as a result of my child's participation in the camp.
- In the event of an emergency where treatment by a doctor is deemed necessary, I hereby give permission for a representative of the Hindu Swayamsevak Sangh to authorize physician(s) and hospital personnel to give my children anesthesia and/or perform whatever medical and/or surgical treatment deemed necessary at such time in my child's best interest.
Signature of the Parent/Guardian Date:
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