Scrap Ohana Summer Camp Registration Form
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June 23rd to June 26th, 2009
or
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July 24th to July 17th, 2009
9:30am-12pm
Name __________________________________________________
AGE __________________ Date of Birth ___________________
Address_________________________________________________
City____________________________ State_________ Zip_______
Phone #_________________________________________________
Moms Name
Dads Name (or Legal Guardian) ___________________________ Contact #_______________
Doctors Name & Number___________________________________
Allergies__________________________________________________
Emergency Contact Name & Number: ________________________________________________
Names of people allowed to pick up your child
1._________________________________________________________
2._________________________________________________________
3._________________________________________________________
***When dropping of your child you must sign them in. When picking up your child you must sign them out and show your ID.
**If you need to cancel you need to give 10 day’s notice to receive a full refund. After 10 days but before 7, you will receive $38 refund. Any cancellation after 7 days, no refund.
THIS DOCUMENT WILL AFFECT YOUR LEGAL RIGHTS AND LIABILITIES
READ CAREFULLY
AGREEMENT FOR THE RELEASE AND WAIVER OF LIABILITY FOR A MINOR CHILD
I REQUEST PERMISSION FOR MY CHILD ________________________ TO PARTICIPATE IN THE SCRAP OHANA SUMMER CAMP.
I ACCEPT AND ASSUME ALL THE RISKS OF INJURY (INCLUDING DISMEMBERMENT, DEATH AND UNFORSEEN ACTS OF GOD) TO MY CHILD. I REPRESENT AND WARRANT THAT I HAVE THE AUTHORITY TO GIVE THIS RELEASE.
I RELEASE AND AGREE NOT TO MAKE OR BRING CLAIM OF ANY KIND AGAINST SCRAP OHANA, ITS OWNERS TRISHA DECOSTA, NELL DASILVA, GAIL LIBAL, OR THE BUILDING OWNERS FOR ANY INJURY (INCLUDING DISMEMBERMENT, DEATH AND UNFORSEEN ACTS OF GOD), TO MY CHILD. WHETHER FROM ANYONE'S NEGLIGENCE OR NOT, OR ANY OTHER CAUSE, ARISING OUT OF MY CHILD'S PARTICIPATION. I ALSO AGREE THAT IF ANYONE MAKES ANY CLAIMS BECAUSE OF ANY INJURY TO MY CHILD (INCLUDING DISMEMBERMENT, DEATH AND UNFORSEEN ACTS OF GOD). I WILL KEEP ALL THOSE RELEASED BY THIS AGREEMENT FREE OF ANY DAMAGES OR COSTS BECAUSE OF THOSE CLAIMS.
I also authorize Trisha DeCosta, Nell DaSilva or Gail Libal to seek medical attention for my child should it be necessary.
DATED________________ Signature: ___________________________________
(Parent or legal guardian)
Print Name:_________________________________
DATED________________ Signature: ___________________________________
(Parent or legal guardian)
Print Name:_________________________________