Mock Trial Freshman Summer Camp

Mock Trial Freshmen Summer Camp

AMHS Room 208 • Dates TBA
Student Name*

First NameLast Name
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Payment Information*

Mock Trial Camp Registration

$100.00

Total

$0.00

Credit Card

Liability and Medical Waiver

Please read carefully and acknowledge the terms below.
Consent Agreement
I grant permission for my child to participate in this AMHS class. This class will take place under the guidance and direction of school employees and/or volunteers from Archbishop Murphy High School.

As parent and/or guardian, I remain legally responsible for any personal actions taken by the above named minor participant.

I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend Archbishop Murphy High School, its officers, directors and agents, and the Corporation of the Catholic Archbishop of Seattle, chaperones, or representatives associated with the event, from connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the school, its officers, directors and agents, and the Corporation of the Catholic Archbishop of Seattle, chaperones or representatives associated with the event for reasonable attorney's fees and expenses arising therewith.
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Signature*
Emergency Information
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Phone Number*
Format: (000) 000-0000.
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Phone Number*
Format: (000) 000-0000.
Physician Name*
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Office Number*
Format: (000) 000-0000.
Preferred Hospital*
Insurance Company*
Policy Number*
Policy Holder*
ArthritisAsthmaBee Sting Allergy - MildBee Sting Allergy - SevereDeafnessDiabetesHeartKidney/BladderSeizuresWears ContactsWears Glasses
Other Allergies (please list type of allergy and reaction whether mild or severe)
Activities in which your child should NOT participate or additional comments
Medical Release
I declare that I am the parent/guardian of child is injured or should require medical attention, I hereby request you to contact our physician. In the event that the doctor cannot be reached, I hereby authorize the necessary medical treatment for my child. I further acknowledge that I will be responsible for any medical or hospital fees or costs associated with my child's treatment. If possible, confirmation of this authorization should be made prior to treatment by calling me at the listed phone number(s).
Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
12911 39th Avenue SE Everett, WA 98208-6159
Ph (425)379.6363 • Fax (425) 385-2875 • www.am-bs.org
Northsound Association for Catholic Education
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Mock Trial Freshmen Summer Camp

Credit Card

Liability and Medical Waiver

Consent Agreement

Emergency Information

Medical Release