This form must be completed for every child attending Kurabu 2017.
Child’s First Name:
Child’s Last Name:
Grade entering in fall 2017:
Parent 1 First Name:
Parent 1 Last Name:
Parent 2 First Name:
Parent 2 Last Name:
My Child will attend the following sessions:
June 26 - June 30
July 10 - July 14
July 17 - July 21
July 24 - July 28
July xx - July xx
** If you require financial assistance please contact us email@example.com
Special information about your child that would be helpful for the Kurabu staff to know:
MEDICATIONS/CONDITIONS: Please list any health problems, mental or physical conditions that might
special planning or consideration for this child’s participation in Kurabu. (Use additional paper if
Note: Kurabu staff will dispense medication under physician’s orders. All medications must be in the prescription
container clearly labeled with child’s name, the type of medication, the dosage, and the times (both am and pm) to
administer the medication. Additional “Medication Administration” forms may be required prior to the start of
By agreeing and typing in my name, I request the Kurabu staff administer medication to my
above named child in the manner described by the physician’s orders.
Date of last tetanus booster:
In Case of EMERGENCY, if unable to locate parents, contact:
Relationship to camper:
(child’s name) has my permission to participate in all
I also authorize Kurabu to use local emergency services in order to secure proper treatment for my child as named
above. By agreeing and typing in my name, I release Oya No Kai, the City of Portland, and Mt. Tabor Middle School
from all liability or responsibility for any accident or injury to my child while at Kurabu.
By agreeing and typing in my name, I consent to and authorize Kurabu to use my child’s name and photograph for
educational and public relations purposes related to Kurabu.
Any directions to the contrary should be specified and signed below.
List any friends that you would like to be in class with your children.
Please Note: In cases when lice is found on a camper's head, his/her parents will be notified
immediately and will be
asked to pick him/her up from the camp. The camper will be allowed to return to the camp after treatment is
complete & no nits are found. Thank you for your cooperation.