Hurst Police Activities League - Summer Camp 2024

(For students going into 5th or 6th grades)

 

1

Camper's Information

 *

Camper's Information

First Name	Last Name	Date of Birth
Home Address	Home Phone	School Name
Grade in the fall	Male	Female

2

Parent/Guardian Information (#1)

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Parent/Guardian Information (#1)

First Name	Last Name
Daytime Phone	Email

3

Parent/Guardian Information (#2)

 *

Parent/Guardian Information (#2)

First Name	Last Name
Daytime Phone	Email

Chisholm Park - 2200 Norwood Drive
DUE TO SPACE LIMITATIONS, ONLY THE FIRST 40 HURST RESIDENT APPLICATIONS WILL BE ACCEPTED
CAMP DATE: June 17 through June 21 from 9 a.m. to 2 p.m.

4

Did you attend PALS Camp last year?

Did you attend PALS Camp last year?

Yes

No

5

Emergency Contact Information

 *

Emergency Contact Information

First Name	Last Name
Daytime Phone	Email address

6

Medical Conditions, Restrictions, and Allergies

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Medical Conditions, Restrictions, and Allergies

List any medical conditions that could restrict activities (i.e. diabetes, asthma, etc.) or any other condition of which camp staff should be made aware:

List any allergies your child has (food, medication, etc.):

7

List those persons authorized to pick up your child

Names

8

HOLD HARMLESS AGREEMENT/MEDICAL AUTHORIZATION Being the legal parent or guardian of the above listed camper, hereinafter referred to as Participant, do hereby agree to the terms of these releases and do give my full consent for his/her participation in the Hurst Police Activities League Summer 2024 program. I fully understand that due to the nature of the program there is a chance of physical injury. I agree to assume all risks described and not described herein. I agree to release, indemnify, and discharge the Hurst-Euless-Bedford ISD, City of Hurst, and each City’s elected officials, officers, employees and agents, and volunteers from any and all claims, including personal injuries and death, demands, causes of action and suits or liabilities which might arise from such participation, including acts or omissions constituting negligence. Further, until such time as I can be notified, I authorize agents of the City of Hurst to administer emergency medication and/or first aid, or to seek and obtain any other medical treatment deemed necessary by authorized medical personnel or licensed physicians. I hereby grant the City of Hurst organizers the right and permission to publish, without charge, photographs of said child taken at PALS Camp. These photographs may be used in publications, including electronic publications, or in audiovisual presentations, promotional literature, advertising, or in other similar ways. Finally, I agree to release or waive any claim that I may have to acquire individually or as guardian for Participant by reason of the described program. I make these waives and releases to legally bind myself, Participant, my executor, heirs and assigns to the fullest extent now and in the future. By executing this Agreement, I/we agree to all of the terms and conditions contained herein and on the Application on this Agreement. **Clicking "submit" serves as your signature.**

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Parent/Guardian Printed Name

For questions regarding PALS Camp or application, contact Bobbi Parker at 817-788-7342 or bparker@hursttx.gov.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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