Summer 2000 Young Writer's Camp
Registration/Permission Form

Oregon Writing Project @ Willamette Unversity

Please fill out form and return it to:____________________________________

General Information
First Name___________________ Last Name______________________________

Last Grade Completed_______________Age________Gender: M or F (circle one)
Parent or Guardian____________________________Home Phone_____________
Work Phone______________Message Phone______________Cell Phone __________
Mailing Address____________________City____________________zip

Transportation home when the program is over: Please check the appropriate space.
_____My child can walk home.
_____I will be responsible for providing transportation home for my child.

All students will participate in the Writer's Camp at Willamette University on Friday, July 14, 2000. Please initial appropriate space below regarding transportation to Willamette University on Friday.
_____I give permission for my child to ride the bus to Willamette University on Friday, July 14, 2000.
_____I will provide transportation to Willamette University for my child on Friday, July 14, 2000.

Participation day/times:
Young writers will attend a total of two days. The first day will be at the site closest to their home (unless other arrangements are made). The second day will be on Friday, July 14 at Willamette University. Please check one site that your child will attend for the first session.
_____Monday, July 10 at Mill City Middle School in Mill City
_____Tuesday, July 11 at Clear Lake Elementary School in Salem
_____Wednesday, July 12 at Myers Elementary School in Salem
_____Thursday, July 13 at Monmouth Elementary School in Monmouth

Permission to photograph
_____I give permission for Young Writer's Camp staff to photograph my child during the camp. I understand that photographs could be used on a website to advertise this camp for next year.
_____I do not want my child to be photographed.

Medical Information
Family Doctor_________________Phone____________Hospital_________________
Medical Insurance Yes_____No_____Insurance Company_______________________
Policy Number______________________
Person to notify in an emergency__________________________Phone ____________
Special instructions regarding emergencies, physical problems, allergies, etc.__________________________________________________________________

I declare that I am the parent or legal guardian of the above named child, and I have custody and control of the child. In the event my child is injured or should require medical attention, I hereby request that you contact our family physician. In the event the doctor cannot be reached, I hereby authorize the Young Writer's Camp staff to secure 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 medical treatment which are not covered by insurance. If possible, confirmation of this authorization should be made with me prior to treatment by calling me at the above listed phone number. In case I cannot be reached for an emergency, medical treatment as described above may proceed without further authorization. I assume all risks and hazards to such participation including transportation to and from the activities and hereby waive, release, absolve, indemnify and agree to hold harmless the Young Writer's Camp Staff, its organizers, sponsors, supervisors, and participants for any claim arising out of an injury to my child whether the result of negligence or for any other cause, except to the extent and in the amount covered by accident or liability insurance.

Parent/Guardian_________________________________ Date _____________________

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