Tara Youth Summer Camp Authorization Form

		TARA SUMMER YOUTH CAMP PERMISSIONS AND AUTHORIZATIONS FORM
		_____________________________
		campers name

Please Print, complete and return or fax to:
Tara Wildlife
6791 Eagle Lake Shore Road
Vicksburg, MS 39183
(601) 279-4261 fax: (601) 279-4227

Read each section carefully and sign and date in the space indicated.

Please circle desired camp:

Spring Camp

Summer
Camp I

Summer
Camp II

Summer
Camp III

Jakes I

PHOTOGRAPHY RELEASE I do hereby authorize TARA to use and reproduce photographs, film, and videotape taken of my child and to circulate same for advertising and publicity purposes of all kinds.

____________________________	____________________________
signature of parent or guardian	date

CAMP ACTIVITIES PERMISSION I do hereby acknowledge that l am aware that my child will be camping, hiking, canoeing and using various weapons. I do hereby give my permission for him/her to take part in these and all other camp activities.

____________________________	____________________________
signature of parent or guardian	date

PICK-UP AUTHORIZATION I do hereby authorize the following person(s) to pick up my child from TARA’s Summer Youth Camp.

1)._____________________	________________________	__________
	________________________	telephone (daytime)
	address

2)._____________________	________________________	__________
	________________________	telephone (daytime)
	address

If there are any changes in these authorizations, I will give written advance notice.

NOTE: list below any special considerations or persons who are never to be authorized to pick up your child.

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

____________________________	____________________________
signature of parent or guardian	date