2017 APPLICATION FORM
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First Name: *

 
Last Name: *

 
Sex: *


 
Address *

 
City *

 
Zip: *

 
Home Phone: *

 
Camper e-mail address: *

 
Parent e-mail address: *

 
Birth Date: *

 
Age when attending camp:

 
School attended: *

 
County:

 
T-shirt size: *


 
EMERGENCY CONTACT

 
Parent / Guardian: *

 
Relationship to camper: *

 
Daytime Phone: *

 
Cell Phone: *

 
Parent / Guardian:

 
Relationship to camper:

 
Daytime Phone:

 
Cell Phone:

 
Other Emergency Contact:

 
Relationship to camper:

 
Phone:

 
CABIN BUDDY (optional)

 
Buddy's Name:

 
Age:

 
ADDITIONAL CAMPER QUESTIONS

 
Why do you want to be a part of the Kat Perkins Badlands Rising Star Camp? *

 
Who are your musical influences? *

 
What are your top 3 favorite songs? *

 
What musical instruments do you play? *

 
What do you hope to learn at camp? *

 
Please paste the link to your 30 second YouTube video here:

 
HEALTH HISTORY

 
Physician: *

 
Phone: *

 
DOES THE PARTICIPANT:

 
Have his/her Hepatitis B Vaccination Series? *

     
 
Have all required immunizations up to date? *

     
 
Take any medications (prescription or otherwise)? *

     
 
Have any allergies or reactions to medications? *

     
 
Have any heart trouble? *

     
 
Have epilepsy, convulsions, or paralysis? *

     
 
Have diabetes? *

     
 
Have any recurring or chronic illness? *

     
 
Have a record of any serious injuries, operations, or past medical treatment? *

     
 
Have any current or recurrent diseases? *

     
 
Have any dietary restrictions? *

     
 
Have any physical or medical disabilities, handicaps, or any other restrictions on normal camp activities? *

     
 
Have a history of psychiatric counseling or hospitalization? *

     
 
Have any behavioral concerns we should be made aware of? *

     
 
Have health/accidental insurance? *

     
 
Insurance Company:

 
Policy/Group #:

 
If you answered "yes" to any of the above questions, please explain. (Attach a separate document if necessary).

 
If camper is on medication, please list:

 
Date of last tetanus shot:

 
Allergies:

 
Acute or chronic medical conditions:

 
Additional pertinet medical information or current health concerns:

 
I give permission for the Kat Perkins Badlands Rising Star Camp to obtain medical treatment necessary for the health and well-being of my child. *

     
 
PARTICIPANT RELEASE & HOLD HARMLESS AGREEMENT

 
While at Kat Perkins Badlands Rising Star Camp, campers may be involved in activities that require exposure to changing weather conditions and use of a variety of equipment. All activities require the complete attention and responsibility of the camper, either individually or as part of a group. Many of these activities involve inherent risks including possible serious personal injury, or property damage. By signing below, in behalf of the camper, I agree to waive, release, and discharge any and all claims for property damages, personal injury, or death which the camper may have or which may hereafter accrue to the camper as a result of participation at Kat Perkins Badlands Rising Star Camp. As parent or guardian for the named camper, I further agree to forever hold harmless and indemnify Kat Perkins Badlands Rising Star Camp, Kat Perkins Music Inc., its agents, and employees from any and all liability arising from any losses of personal property or any bodily injury incurred by the camper on or off camp property, or in connection with any camp activities or programs. I will defend & indemnify Kat Perkins Badlands Rising Star Camp, Kat Perkins Music Inc., and others named herein from any loss or damage including any that results from claims or lawsuits for personal injury, death, property loss, and damage brought on behalf of the named camper relating in any way to participation through Kat Perkins Badlands Rising Star Camp.

     
 
PHOTO / MEDIA RELEASE

 
I grant permission to Kat Perkins Badlands Rising Star Camp and persons acting for or through them, the right to use, reproduce, and/or distribute photos, films, videos, and sound recordings involving the participation of the individual identified on this form at Kat Perkins Badlands Rising Star Camp use in any promotional materials they may create.

     
 
Application complete!
Please proceed to Kat's web store (katperkins.bigcartel.com) for payment of $25 for this application. (This fee will go towards full balance upon camper acceptance.) Thank you!

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