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2020 Summer Camp Registration
Registration for Fox Valley Wildlife Center Summer Camp. Please complete the form in its entirety.
Camper's Name *
Your answer
Camper's Birthday *
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Returning Camper? *
Grade Level Camper is Entering Fall 2020 *
Which days of camp is the camper attending? *
Required
T-Shirt Size *
Your answer
Parent/ Guardian Name *
Your answer
Relationship to Camper *
Your answer
Parent/ Guardian Phone Number *
Your answer
Parent/ Guardian Address *
Your answer
Parent/ Guardian Email *
Your answer
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #2 Name *
Your answer
Emergency Contact #2 Phone Number *
Your answer
Restrictions: Camp activities will be held outdoors in varying terrain with unpredictable weather. Please indicate any restrictions the camper may have or simply type "none". *
Your answer
Health Care Provider's Name, Phone, Practice Name and Address *
Your answer
Insurance Carrier/ Plan's Name, Policy Number, Subscriber's Name and Relationship to Camper *
Your answer
Medical History: Please select any conditions that apply to camper. *
Required
Mental, Emotional and Social History: Please select any options that apply to camper. *
Required
Allergies: Please list all environmental, food, drug allergies that camper may have.
Your answer
Diet *
Required
Please list any medications the camper will be taking during camp hours.
Your answer
Medical Waiver and Authorization (agreement is required for participation): **Medical Release: This health history is correct and accurately reflects the known health status of the named camper. The camper described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to camp staff to provide routine health care; to administer prescribed or over-the-counter medications as described; and to provide or obtain emergency care and transportation for the camper if needed. I give permission to the physician selected by the camp to order x-rays, tests, and treatment related to the health of my child both for routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order and administer medication, injection, anesthesia, X-rays, special procedures, or surgery for this child, if deemed medically necessary. I understand that I am responsible for the cost of any medical care or prescriptions my child requires. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I understand that information on this form will be shared on a "need to know" basis with camp staff. **Medications: I authorize Fox Valley Wildlife Center’s designated staff to administer as listed above medications at camp, as directed, to my child for whom it was prescribed. I understand that all medications at camp must be seen and checked by the camp’s supervisor, and each dose monitored by a camp staff member. I understand that all medications must be in their original containers, unexpired, and labeled with specific instructions, including the child’s name and dosage, and that any prescription medications must include the full pharmacy label. **Insurance: I certify that the named camper is covered by health and accident insurance or Medicaid and that the policy information given is correct. I, the parent/legal guardian of the named camper, have read, understood, and agree to the above. **Please type your name below** *
Your answer
Day Camp Audio/Visual Image Release: Fox Valley Wildlife Center uses images and sounds of children and staff participating in Fox Valley Wildlife Center programs as a way of documenting the enjoyable and educational experiences they have while exploring the natural world. Fox Valley Wildlife Center will not identify my child, or will identify my child only by first name and program, unless I give prior written permission to do otherwise. In consideration of the above, I hereby give my permission and consent to Fox Valley Wildlife Center (1) photographing, filming, and video/audio taping my child, (2) using and displaying images and sounds of my child in Fox Valley Wildlife Center ‘s websites, archives, and promotional or informational material, including, but not limited to, newsletters, brochures, advertisements, and newspaper articles, and I hereby waive and release on behalf of my child and myself any rights to compensation for, or ownership of, such images and/or sounds of my child and the above uses of them by Fox Valley Wildlife Center. I have read this audio/visual image release and agree to its terms and conditions. **Please type your name below**
Your answer
Day Camp Agreement of Terms: **Program: I give permission for my child to participate in all camp program activities similar to those described in the camp advertisement. I understand that Fox Valley Wildlife Center reserves the right to change program activities or instructors and cancel programs, should Fox Valley Wildlife Center decide in its sole judgment that it is necessary and appropriate to do so. **Expectations/Dismissal: I have informed the Camp Director and other appropriate Fox Valley Wildlife Center staff of any limitations to my child’s participation and agree to abide by Fox Valley Wildlife Center’s sole judgment as to whether my child can be accommodated in the camp program. I understand that failing to disclose any physical, emotional, or behavioral needs or conditions may result in the child’s dismissal from the program without refund. I understand that my child must follow the stated behavior expectations and safety rules and that Fox Valley Wildlife Center reserves the right in its sole judgment to dismiss without refund any child whose behavior interferes with the rights and safety of others or consistently disrupts group dynamics or activities. **Sun and Bugs: I understand that outdoor exploration is an integral part of Fox Valley Wildlife Center programs and my child will be exposed to risks including but not limited to sun, ticks, and insects. I understand that it is my responsibility to apply sunscreen and insect repellent to my child before bringing him/her to camp each day. I give permission to Fox Valley Wildlife Center staff to assist my child in re-applying sunscreen, insect repellent, and topical anti-itch cream. I understand that some ticks may transmit disease after being attached for over 24 hours, and it is my responsibility to check my child’s body thoroughly every day and to remove any ticks that may become attached. I am responsible to do a complete check upon my child’s return home. **Payment, Cancellation, and Refund: I understand and agree to the payment policies as described in the camp’s advertisement. I have read and agree to abide by the terms and policies listed above and those found in the camp advertisement. I, the parent/legal guardian of the named camper, have read, understood, and agree to the above. **Please type name below**
Your answer
Day Camp Acknowledgement of Risk and Assumption of Personal Responsibility:Fox Valley Wildlife Center staff members make every effort to conduct safe programs, to orient and support children, and to inform families of inherent risks. Some activities may involve risks that children do not routinely encounter at home. Risk management is an essential element of all the activities offered. While we anticipate that these efforts will ensure the well being of each child, we are also aware that it is neither possible to foresee every contingency nor to eliminate all risk. I understand that program activities may include, but are not limited to: hiking on uneven terrain, playing active games, participating in activities near water and being near program animals. Other risks may be inherent in program activities. I acknowledge that such risks exist, and I hereby agree on behalf of my child to assume such risks. Further, on behalf of my child, I hereby release and forever discharge, and agree not to sue, and agree to indemnify and hold harmless Fox Valley Wildlife Center, and its officers, directors, employees, and volunteers and each of them, from and against any and all liabilities and obligations of every kind and description, which I shall or may have against them or any one or more of them arising out of, or in connection with, my child’s participation in the Fox Valley Wildlife Center program and activities, including, but not limited to, for any personal injury that my child may suffer while participating in the Fox Valley Wildlife Center program and activities, excepting in the case of gross negligence. I understand and agree on behalf of my child that my child shares the responsibility for safety during Fox Valley Wildlife Center programs and activities, and I personally assume on behalf of my child that responsibility. I understand and certify that my child’s participation in the Fox Valley Wildlife Center program and its activities is completely voluntary, and that I have become familiar with the program activities in which my child may participate, as described in the Agreement of Terms or camp advertisement. **Please type name below**
Your answer
Digital Acknowledgment: I understand that by electronically submitting this form, the typing of my name on this form serves as an equivalent to signing registration forms in ink. At my request, FVWC will print this form for me to sign in ink. **Please type name and date below**
Your answer
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