Winter Camp

2. 
3. 
5. Camper 1
7. Camper's First Name*
8. Camper's Last Name*
10. Gender
    -- Select One --MaleFemale Prefer not to say
11. Date of Birth*
    Date of Birth
12. School*
13. Grade*
15. Does the child have any allergies?
17. Does your child have any special need, dietary restictions or are any special circumstances we should be aware of?
18. Any medications we should be aware of?
22. Camper 2
24. Camper's First Name
25. Camper's Last Name
27. Gender
    -- Select One --Male FemalePrefer not to say
28. Date of Birth
    Date of Birth
29. School
30. Grade
32. Does the child have any allergies?
34. Does your child have any special need, dietary restictions or are any special circumstances we should be aware of?
35. Any medications we should be aware of?
39. Camper 3
41. Camper's First Name
42. Camper's Last Name
44. Gender
    -- Select One --MaleFemale Prefer not to say
45. Date of Birth
    Date of Birth
46. School
47. Grade
49. Does the child have any allergies?
51. Does your child have any special need, dietary restictions or are any special circumstances we should be aware of?
52. Any medications we should be aware of?
56. Parent / Guardian #1
58. Parent / Guardian First Name*
59. Parent / Guardian Last Name*
61. Address*
63. City*
64. State*
65. Zip Code*
67. Email*
68. Mobile*
69. Other phone (home or work)
73. Parent / Guardian #2
75. Parent / Guardian First Name
76. Parent / Guardian Last Name
78. Address
80. City
81. State
82. Zip Code
84. Email Address
85. Mobile
86. Other phone (home or work)
90. Emergency Contact Information

    Please list emergency contacts (other than the Parents/Guardian). Parents/Guardian will be contacted first.  

92. First Name*
93. Last Name*
95. Camper Relationship*
    -- Select One --Parent Step-Parent Mother Father Grandmother GrandfatherAunt UncleSiblingOther
96. Can pickup child*

    1. Yes
    2. No
97. Phone*
99. First Name
100. Last Name
102. Camper Relationship
     -- Select One --ParentStep-ParentMother Father Grandmother GrandfatherAuntUncleSiblingPartnerOther
103. Can pickup child

     1. Yes
     2. No
104. Phone
106. ALL CAMPS

     Please list individuals authorized to pick your child up after camp in addition to parents/Guardian and emergency contacts (A Photo ID is requested from the individual at pick up.)  

108. Name
109. Relationship
     -- Select One --ParentStep-ParentMother Father Grandmother GrandfatherAuntUncleSiblingPartnerOther
111. Name
112. Relationship
     -- Select One --ParentStep-ParentMother Father Grandmother GrandfatherAuntUncleSiblingPartnerOther
114. Name
115. Relationship
     -- Select One --ParentStep-ParentMother Father Grandmother GrandfatherAuntUncleSiblingPartnerOther
117. Name
118. Relationship
     -- Select One --ParentStep-ParentMother Father Grandmother GrandfatherAuntUncleSiblingPartnerOther
120. Emergency Transportation Notice

     Please note that in the event you or the designated emergency contact cannot be reached within 15 minutes of injury, the paramedics will take the camper to the local hospital. If on a field trip, camper will be transported to the closet area hospital, by paramedics.

122. Consent and Authorization

     I understand that the North Riverside Recreation Department and all employees working for the Department and the Village

     are not liable for any accidents or injuries incurred. By partaking of classes, in or out of town, or on trips, I assume all

     responsibility in case of injury and financial liability for medical expenses. By partaking in any recreation program, I

     release, waive, absolve, and indemnify the above from any financial responsibilities. It is recommended that the participant

     review his/her own personal insurance policy for adequate coverage during all program activities. I hereby consent to the

     use of my photograph in the North Riverside Recreation brochures, publications, slide presentations, etc.

     I further agree to abide by all policies and procedures set forth by the Recreation Department in the Day Camp Parent

     Manual as well as the Day Camp Behavioral Guidelines. I have read and understand the parent manual and agree to follow

     all policies and procedures set forth in the manual.

     Medical Release: In the event that no one can be reached, I hereby give my permission for my child to receive necessary

     emergency transportation and/or treatment. I agree to the emergency transportation notice on the reverse side of this form.

     Refund and Cancellation/Transfer Policy: Refunds for Camp will be issued only if a replacement person is found and

     enrolled. Spaces cannot be held. A $10 fee will be assessed for transfers.

     I, as the signee/authorized guardian, agree to all aforementioned information.

124. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
126. Electronic Signature
Leave This Blank:


128. 1. Receive an email copy of this form.
129. Email address

     This field is not part of the form submission.

130. Submit

* indicates a required field