Camp Carnival Fun Day
July 20, 2018, 5-8pm at Camp Liahona, 6700 Chambersburg Road, Fayetteville, PA 17222
Email address *
I understand this event is being hosted for ASGHA families by a Third Party (ALL adults on site have appropriate PA volunteer child clearances and event staff have worked closely with ASGHA to provide a fun event for everyone. A member of the ASGHA Board will be on site during the event.) I understand that the event has been created for individuals with autism and their siblings ages 3-18 years and a parent/caregiver must remain on-site with participant throughout the event. I will include all required information completely (Enter NONE for any additional registrant spaces). I will print a copy of my registration for my records. The only confirmation of registration will be the notice provided at the completion of this form. By registering I agree my family does plan to attend the event. NO SHOWS will be placed on the bottom of all future summer events. *
Last Name (Registering Adult/Caregiver-Primary Contact for event) *
Your answer
First Name (Registering Parent/Caregiver-Primary Contact for event) *
Your answer
Telephone (Primary Contact-must provide valid number WITH area code) *
Your answer
Total Number of children ages 3-18 years Attending Event *
Your answer
Number of individuals with ASD attending the event? *
Your answer
Have you attended this event before? *
County of Residence *
Registrant #2 (Last Name, First Name-Second Parent/Caregiver)
Your answer
Registrant #3 (Last Name, First Name, Age) *
Your answer
Registrant #4 (Last Name, First Name, Age)
Your answer
Registrant #5 (Last Name, First Name, Age)
Your answer
Registrant #6 (Last Name, First Name, Age)
Your answer
Please list any additional immediate family members (Last Name, First Name, Age)
Your answer
WAIVER/PHOTO RELEASE: In consideration of my desire to participate in the events and related activities sponsored by the Autism Society Greater Harrisburg Area (ASGHA), I agree to assume all risks attendant thereto and, thus, hereby release, hold harmless and forever discharge ASGHA and each and every officer, director, agent, employee, and authorized volunteer from all claims, causes of action, judgments, damages or demands, of any kind from or by myself, heirs, executors, administrators and assigns, for personal injuries and property damage which I may cause or sustain during the event whether known or unknown, foreseen or unforeseen. I agree to indemnify and defend ASGHA for liability arising from any tortuous acts or omissions. I also understand photographs/videos may be taken during the event which may be used on ASGHA's website, listserve or various social media platforms at the discretion of the ASGHA board/staff and agree to release all rights forthwith. I am aware that this is a waiver, release of liability and photo/video release between myself, those registered in my party, and all of the parties named above, and sign it (by hand and/or electronically) on my own free will. (Please type initials as electronic signature) *
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A copy of your responses will be emailed to the address you provided.
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