Pioneer Life Camp Registration Form Summer 2018
Camper's Name *
Your answer
Parent or Guardian's Name *
Your answer
Complete Mailing Address *
please include zipcode
Your answer
Primary phone number *
Your answer
Email address (if available)
Your answer
Grade that camper will enter in Fall 2018 *
Camper's birthdate
Your answer
Camper's gender
Return Camper?
If yes, list previous summers (years) attended
Your answer
Please indicate session you are registering for *
Please indicate transportation option *
Clothing Size *
shirt size for boys; dress size for girls
Your answer
T-shirt size
Emergency Contact *
Please list name, best number to reach person and relationship
Your answer
Additional Emergency Contact
Please list name, best number to reach person and relationship
Your answer
Please list name of any individual who is NOT authorized to pick up your child
Your answer
Does the camper have any physical condition which we should be aware? This includes food and/or medicine allergies, hyperactivity, learning disabilities, behavior disorders, or medical conditions.
Your answer
Does the camper require special attention, medication or routines that may have to be taken into consideration during the daytime?
Your answer
Please list any concerns that you or your child would like us to be aware of.
Your answer
Preferred Physician
Name and phone number
Your answer
Preferred Hospital *
Health Insurance Information
Insurance company and policy number
Your answer
Permission is granted for my child to be photographed during his/her attendance at the Pioneer Life Day Camp programs. This consent releases from liability all personnel of the State of Illinois, Lincoln's New Salem State Historic Site, the New Salem Lincoln League and Illinois College and any others who have received permission to take photographs during the Pioneer Life Day Camp programs. This consent also gives permission for photographs taken to be used in publicity or publications for the State of Illinois, Lincoln's New Salem State Historic Site, the New Salem Lincoln League and Illinois College. *
Required
Permission is granted for the Pioneer Life Day Camp programs, Lincoln's New Salem State Historic Site, and Illinois College to post camp pictures that include my child on their respective Facebook pages. Full names of campers will not be used when posting pictures. *
Required
Please read the document below and check that you understand and accept the Illinois College Program Waiver and Policy Statement. *
Illinois College Program Waiver and Release
My child intends to participate in the Illinois College Pioneer Life Day Camp program (“Program”) approved by Illinois College (“College”). In consideration for being permitted to participate in the Program, the receipt and sufficiency of which is hereby acknowledged, I agree and represent as follows:
1) I understand that the College reserves the right to establish rules for participation in the Program, and my child will comply with those rules. The College, in its sole discretion, may terminate my child's participation in the Program if he/she violates the rules or behaves in a manner which is disruptive or which could impede or obstruct the progress of the Program in any way, or affect adversely the reputation of the Program or the College. I understand that, if my child's participation in the Program is terminated, I will not receive a refund of any Program fees.

2) I understand that, although the Program in which my child will participate makes every reasonable effort to assure my child's safety while participating in the Program, I hereby acknowledge my awareness that my child's participation in the Program may expose my child to risk of property damage and bodily or personal injury, including death. I understand that the risks my child may encounter include motor vehicle accidents and other travel-related accidents; cuts, bruises, broken bones, sickness, other injuries and health-related occurrences; criminal acts and/or terrorism, as well as other risks that may not be foreseeable. I have investigated the risks, and I hereby assume any and all such risks, and I release and promise not to sue Illinois College or its trustees, officers, employees, agents, successors and assigns.

3) For the sole consideration of the College arranging for my child's participation in the Program, I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby release and forever discharge the College and its governing board of trustees, their members individually, and their officers, age ts and employees (in their official and individual capacities) from any and all claims, demands, rights and causes of action of whatever kind, arising from or by reason of any personal injury, property damage, or the consequences thereof, resulting from or in any way connected with my participation in the Program and/or any travel incident thereto, including any acts of negligence on the part of the College, its trustees, officers, employees or agents.

4) I have or will secure comprehensive health and accident insurance for my child to provide adequate coverage for any injuries or illnesses that he/she may sustain or experience while participating in the Program. By my signature below, I certify that I have confirmed that my child's health care coverage will adequately cover him/her while he/she participates in the Program, and I hereby release the College, and its employees and agents, from any responsibility or liability for expenses incurred by me for injuries or illnesses (including death) that my child may incur because of those injuries or illnesses, including medical bills, charges and similar expenses.

5) I authorize any representative of the College to secure dental and medical treatment for my child if he/she is injured or becomes ill while participating in the Program, including without limitation anesthetic and surgical treatment, and further authorize any representative of the College to sign authorization forms necessary to obtain the treatment. Neither the College nor its employees and agents shall be responsible or liable for any expenses or damages I may incur as a result of the College acting pursuant to this grant of authority.

6) I, individually, and on behalf of my heirs, successors, assigns and personal representatives, agree to indemnify, defend and hold harmless the College, and its trustees, officers, employees, agents, successors and assigns (in their official and individual capacities), from any and all liability, loss, damage, claim, suit and cost which arises out of, occurs during, or is in any way connected with my child's participation in the Program or any travel incident thereto, including claims and suits arising out of any of my alleged acts or omissions, and any claim or suit made on my behalf by my legal representatives, heirs, successors and assigns.

7) I agree that, should any provision or aspect of this agreement be found to be unenforceable, all remaining provisions of the agreement will remain in full force and effect.

8) I represent that my agreement to the provisions herein is wholly voluntary, and further understand that, prior to signing this agreement, I have the right to consult with the advisor, counselor or attorney of my choice.

9) I agree that, should there be any dispute concerning my child's participation in the Program that would require the adjudication of a court of law, such adjudication will occur in the courts of, and be determined by the laws of, the State of Illinois. Unless the College agrees otherwise, venue shall be in Morgan County, Illinois.

This agreement represents my complete understanding with the College concerning the College’s responsibility and liability for my child's participation in the Program, supersedes any previous or contemporaneous understandings I may have had with the College on this subject, whether written or oral, and cannot be changed or amended in any way without my written concurrence.

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