Supplemental Information       ( step 4 of 6 )

camper registration for Fred Tester : phones: 415-555-1212 email: tester2@casparinstitute.org

I authorize (Please initial each item)
BSSC to seek emergency medical treatment for my child if I cannot be located.
BSSC personnel to transport my child to activities.
BSSC to give Tylenol to my child.
My child to swim without a life jacket.
Photographs of my child may be used for camp promotion brochures, website, etc.)
I agree (Please initial each item)
That I will not hold Bolinas Community Center, or the BSSC director, staff, or counselors responsible for injury or illness, except in cases of gross negligence.
That I understand that BSSC holds liability, accident, and medical insurance on an excess basis and that it pays the deductible if the family has its own insurance or provides primary coverage up to its limits if not.
Winken, Blinken, & Nod
This contact information applies
to any of these campers
(If not, please fill out individual forms.)
Emergency Contacts
If you cannot be contacted,
who should we notify?
Medical Information
Preferred Hospital: Marin General
Kaiser Permanente
Insurance Co.:
Policy #:

Please use the space below to describe any Allergies, health problems, pre-existing conditions, current medications, or special instructions we might need to know.

Name of person completing this form:

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Bolinas Stinson Summer Camp
Box 1034
Bolinas, California 94924

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