MIFA COOL Summer Camp Application
Please fill in all blanks and print legibly. Return completed forms to MIFA COOL, 910 Vance Ave., Memphis, TN 38126, or .
Camp site
Student Information
Last name First name Male Female
Date of birth / / Age Current grade
School
Address
City State ZIP code
Preferred phone number Secondary phone number Email address
Names of other students attending camp
Transportation Information
Name of person picking student up
Relationship Phone number
Alternate person picking student up
Relationship Phone number
Will student be walking? £ Yes £ No
Parent or Legal Guardian Information
Parent one—Last name First name
Address
City State ZIP code
Home phone number Work phone number
Cell phone number Email address
Employer
Parent two—Last name First name
Address
City State ZIP code
Home phone number Work phone number
Cell phone number Email address
Employer
Additional Emergency Contact Information
Please provide contact information for a designated person who should be contacted if a parent or legal guardian cannot be reached.
Name Relationship
Phone number Email address
Medical Information
Is the student under a doctor’s care or on any type of medication? £ Yes £ No
If yes, specify the type of medication and nature of the illness
Physician’s name Phone number
Health care provider/hospital
Insurance company
Does the student have any allergies? £ Yes £ No If yes, please list
Parent Agreement & Media Release
My youth has permission to participate in MIFA COOL Summer Camp. £ Yes £ No
I do hereby authorize MIFA COOL and its partners to use photo, videos, and recordings of my youth taken during any 2015 MIFA COOL Summer Camp and related programs for the purpose of publicity on the MIFA website, in brochures, or other means publicity. I also understand that my child may be identified by name when media is used.
Signature of parent or legal guardian Date
I hereby fully release and discharge, and agree to hold harmless MIFA COOL, its officers, agents, and employees from any and all liability, claims, demands, rights of causes of action, present or future, whether known or unknown, anticipated or not anticipated, which may occur as the result of my participation in the 2015 MIFA COOL Summer Camp, even under circumstances in which such personal injury, illness, death, property damage or loss is caused in whole or in part by the action, inaction, or negligence of MIFA COOL, to the fullest extent permitted by law. I expressly and voluntarily assume all risk of injury, illness, and death, and property damage or loss that may result from my participation in the summer camp.
I acknowledge that I have read this agreement in its entirety and I fully understand the risk of participating in the 2015 MIFA COOL Summer Camp. I am fully aware that this agreement will have the effect of releasing MIFA COOL of kind which may occur as a result of my participation in the MIFA COOL Summer Camp. I agree to assume the full risk of any injuries, damages, loss, or death, regardless of the severity, my youth may sustain while participating in the MIFA COOL Summer Camp.
I have reviewed this application and fully understand and agree to all of the above stipulations.
Signature of parent or legal guardian Date