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Youth Information

Parent / Guardian Information

Parent / Guardian #2

Alternate Pick-up / Release

Medical / Insurance Information

Please list any medical problems, including any requiring maintenance medication (i.e. diabetic, asthma, seizures)

Emergency Contact(s)

I understand that I will be notified in the case of a medical emergency involving my youth. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my youth is injured or becomes ill.

I understand that Black Arts MKE Youth Performing Arts Camp will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

Photography / Photography Release

I hereby give permission for my child to be photographed during the Black Arts MKE Youth P-Arts Summer Camp. I understand the photos/videos will be used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph/video may be used for promotion, his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of Black Arts MKE Youth P-Arts Summer Camp.

The Black Arts MKE Youth P-Arts Summer Camp and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. Photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician).