Camper Information

Camper's First Name:* Camper's Last Name:*

Birth Date:* MM/DD/YYYY

Gender:* FemaleMale

Grade in Sept. 2010:* ---Select--- K 1 2 3 4 5 6 7 8 9 10 11 12 School Attending:

Camp Program:* ---Select--- Wee Folks Camp Little Folks Camp Ranger Camp Explorer Camp Voyager Camp Camp Location:* ---Select--- Canyon Country Park Newhall Park North Oaks Park Santa Clarita Park Valencia Glen Park Valencia Meadows Park

Parent/guardian email:*

Address: City: Zipcode:

Home Phone:

Father/Guardian:* Work Phone:* Cell Phone:*

Mother/Guardian:* Work Phone:* Cell Phone:*

* Please provide full name for the Parent/Guardian

EMERGENCY CONTACT AND PERSONS AUTHROIZED TO PICK UP MY CHILD

(Other than parents and must be 18 years or older)

Name:* Relationship:* Phone:*

Name: Relationship: Phone:

Name: Relationship: Phone:

Name: Relationship: Phone:

WALK HOME FROM CAMP PERMISSION

IF YOU WISH TO HAVE YOUR CHILD WALK HOME FROM CAMP UNACCOMPANIED, PLEASE SET A TIME.
An original signature is also required, therefore, you will be asked to sign this form on your child’s first day of camp.

Time to be released:

MEDICAL INFORMATION

Note:Any medication dispensed to your child must be brought to camp in its original prescription container and a separate form must be filled out.

Is camper on medications:* YesNo Name of medication:* Amount:* Frequency:* Allergies/Medical Conditions/Dietary Restrictions:

Please list any allergies (medication, food, other), medical conditions and/or dietary restrictions we should be aware of

INSURANCE INFORMATION

Carrier/Plan Name Group Policy Number Name of insured

Name of Physician Address Phone Number

Name of Dentist Address Phone Number

PERMISSION TO PARTICIPATE / CAMP POLICIES AND PROCEDURES

Electronic Parent/Guardian Signature (required)

Yes — I voluntarily agree to allow my child to participate in the above named program. I understand that:

1) There are no make-ups or transfers of money. 2) Staff reserves the right to require proof of age at any time. 3) For safety purposes, camp T-shirts and closed toe shoes with rubber soles must be worn daily. Campers will not be permitted into camp without them. NO EXCEPTIONS. 4) Camp hours are from 7:00am to 6:00pm. 5) Staff is not responsible for lost or stolen articles. 6) Campers are required to have self-discipline and follow instructions in order to provide a safe and constructive environment for everyone.

I hereby waive, release, and hold harmless from any liability for damages or claims for damages for personal injury including accidental death, as well as from claims for property damage which may arise in connection with the above named activity, against the Supervisors, City of Santa Clarita, and its elected and appointed officials, agents, and employees. As a parent/guardian, I hereby consent to treatment of my minor child for any and all medical procedures deemed necessary as a result of accident or injury. I further agree to pay any and all costs incurred as a result of said treatment. I hereby give permission to the City of Santa Clarita to use my child(ren)’s photographs as they see fit in their recreational brochure. I understand the photographs belong to the City and I will not receive payment of any kind. I have read and understand the Permission to Participate/Camp Policies and Procedures and further understand that transgression of any policy is cause for immediate expulsion from the program without refund. I also understand that only minor discipline problems will be handled in this program and recurrent behavioral problems of any kind may result in temporary or permanent suspension from the program.

An original signature is also required, therefore, you will be asked to sign this form on your child’s first day of camp.