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2022 Camper Information Sheet

City of Elgin
2022 Camper Information Sheet
Which camp will your child attend?*
School
Grade Entering in Fall*
Child's Name*
Gender*
1. Male
2. Female
Birthdate*
Birthdate
Address*
City*
Zip*
Cell Phone*
Home Phone*
Email*
Child's Primary Residence/Physical Custody*
If Other, Enter Name
Parent 1's Name*
Parent 2's Name
Parent 1's Cell Phone*
Parent 2's Cell Phone
Parent 1's Work Phone
Parent 2's Work Phone
Emergency Contact*
In case parent/guardian cannot be reached
Phone*
Emergency Contact/Persons Authorized to Pick Up Child
Parents/Guardians must be listed.
I authorize The City of Elgin to release my child to the following person(s),
No changes to this list will be effective unless they are provided in writing. I understand that persons on this list may be required to show a photo ID prior to the release of any child. I further waive and release the City of Elgin, its employees, agents, volunteers, representatives, boards and commissions from and against any and all liability of whatsoever nature arising out of or in connection with any person being permitted to pick up my child.
Name - acts as signature*
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship
Camp Discipline Acknowledgement
Campers are expected to behave and follow camp rules while they attend camp. Campers may be asked to stay home from camp if discipline problems persist. I understand that I will be notified in advance of discipline problems and that I will not receive a refund for days missed for disciplinary reasons.
Name - acts as signature*
Field Trip Permission
I give my child permission to attend field trips scheduled by the camp staff including trips to Wing Park/The Centre of Elgin on Tuesdays and Thursdays. I understand that I will be notified in advance of the trip locations. I also am aware that my child could be asked to stay home from a field trip for disciplinary reasons while at camp. If I choose not to send my child on a field trip, I will still be responsible for full payment of the session and finding alternate childcare.
Name - acts as signature*
Permission to watch G and PG rated movies:
Enter your Name - acts as signature
Medical Information
Special Needs:*
Yes
No
If yes, please explain
Allergies and Common Reactions:
Is Camper presently taking any medications?*
Yes
No
If yes, name of medicine and condition being treated.
Will medicine be taken while child is at camp?
Yes
No
Medical form will need to be filled out if child will require medicine at Camp.
If yes, what times will medicine be taken?
Does child have diabetes, epilepsy, hyperactivity, autism or any other medical/emotional condition that his/her counselor should know about?*
If none, enter N/A
Name of Physician
Physician Phone Number
Permission to seek medical treatment
I give City of Elgin staff permission to seek medical treatment for my child in case I cannot be reached. I give permission for my child to be transported to the nearest hospital and to the hospital officials to begin treatment of my child. I understand that the City of Elgin and the day camp are not responsible for any medical bills that may be incurred.
Name - acts as signature*
Program Waiver
WAIVER: I hereby agree and understand, in exchange for good and valuable consideration, including but not limited to the services and access provided with my membership, the receipt and sufficiency of which are hereby acknowledged, that I (or to the extent I am signing on behalf of any of my family members including but not limited to the minor children) assume and acknowledge the risks inherent in the above-mentioned activities and further agree to the fullest extent permitted by law to indemnify, defend, waive and hold the City of Elgin, its officials, officers, employees, agents, independent contractors or any other related person or entity, harmless from and against any and all liability, claims for damages, causes of action, judgments or suits to which I or my family members, heirs or assigns may otherwise be entitled, resulting from my or my family member’s membership and/or participation in the above program(s). I further understand that no hospitalization, health or accident insurance coverage has been provided with this registration. I hereby consent to any above listed minor or other person’s participation in any programs provided for hereby and consent to emergency medical treatment for any such minor or other person. I further hereby warrant and represent that I have legal parental or other lawful authority to so consent and register any such aforementioned minor or other person. I further warrant and represent that I am fluent in the English language and have read and understand all of the provisions of this form. To the best of my knowledge, there are no physical or other conditions which may interfere with my participation or the participation of any minor or other person for whom I am signing this waiver and registration in this program or which may unreasonably endanger any other person. I also acknowledge and hereby agree to abide by the City of Elgin’s refund/cancellation policy. In the event that the duty to defend provisions of this paragraph are invoked, counsel for the City of Elgin’s defense shall be of the City of Elgin’s choosing. The provisions of this waiver shall survive any termination and/or cancellation of any affected person’s membership. In the event that this waiver is submitted unsigned or altered, registration in the above-mentioned activity will not be allowed.
Name - acts as signature*
Date*
Date

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2022 Camper Information Sheet

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