SMI Camper Release Dismissal Form
This form is to be completed, prior to the start of camp, if a camper will need to be dismissed from any portion of camp, or leave with a parent/guardian, while camp is in session.
Camper Name *
Date(s) of Release, Time(s) of Release, Return Time(s) of Release *
Parent/Guardian Name picking up the camper. Please indicate the date if there are multiple names submitted. *
Parent/Guardian Cell Phone Number *
I understand that if the camper chooses not to return or fails to return for the remainder of the camp session, all fees will be forfeited. I agree and do hereby release from liability and to indemnify, hold harmless, and promise to not take legal action against Summer Music Institute, Western Illinois University and any of its employees or authorized agents representing or related to the University with regard to the WIU Summer Music Institute, from any liabilities or claims made as a result traveling to and from this event, whether caused by the negligence of release or otherwise. *
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