Fall 2018 - New - CCS - Camp Funderblast

New Funderblast Family - Cascade Canyon School - Winter/Spring 2018

* Indicates required field

Parent/Guardian 1 - Name *

First

Last

Parent/Guardian 1 - Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Parent/Guardian 2 - Name *

First

Last

Parent/Guardian 2 - Email *

Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number (if different) *

Cell Phone Number *

Work Phone Number *

Child 1 - Name *

First

Last

Age *

Date of Birth *

Grade *

School *

After School Drop In Camps • Monday-Friday 3pm-6pm *

1 Drop In Day ($30) 10 Drop In Days ($280) 20 Drop In Days ($540)

Child 2 - Name *

First

Last

Age *

Date of Birth *

Grade *

School *

After School Drop In Camps • Monday-Friday 3pm-6pm *

1 Drop In Day ($30) 10 Drop In Days ($280) 20 Drop In Days ($540)

Payment Method *

Cash Check

In Case of Emergency (ICE) Contact - Other than Parents/Guardians *

First

Last

ICE Phone Number *

Permitted To Pick Up my Child *

First

Last

Phone Number *

Family Doctor *

Phone Number *

Insurance Carrier and/or Medial Plan *

Any Allergies? *

Does Either Child Require an Epi-Pen? *

Yes No

Any additional medical issues we should know about? *

Please list all current medications regardless of whether it needs to be taken at camp or not: *

Any activities to be restricted for health reasons: *

Any additional info we should know (e.g. my child has a tendency to wander off etc.) *

WAIVER AND RELEASE OF LIABILITY FOR MINORS. In consideration for permission to participate in any activity at Camp Funderblast (“Camp”) today and on all future dates, I, for myself, and on behalf of the minor child(ren) identified above (“Participant”), our heirs, personal representatives and/or assigns, do hereby release, waive, discharge, and covenant not to sue Funderblast LLC, Homestead Valley Community Association, Scott Valley Swimming & Tennis Club, the County of Marin, or Cascade Canyon School a tenant of Saint Rita’s Catholic Church (collectively referred to herein as, “Indemnified Parties”), their directors, officers, owners, employees, counselors or volunteers, from liability for any and all claims for personal injury, illness, death, property damage, or any other claim, including but not limited to claims arising out of the negligence of Indemnified Parties, their employees or their agents. This waiver and release of liability applies to all Camp activities, regardless of whether participation requires the Participant to leave Camp premises and regardless of whether a separate fee was charged for the activity. In case of a medical or surgical emergency, I hereby give permission to any medical personnel selected by the Camp staff to administer treatment. I will assume full responsibility for any such action, including payment of all costs. It is understood that Indemnified Parties will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I hereby agree that any pictures or videos of Participant(s) may be used for Camp training, advertising, or promotion without any compensation to me or Participant. I acknowledge that some Camp activities may pose risks to Participant, including the risk of serious injury or death. By checking the box below I agree to all terms and conditions set forth above and give my consent for the listed participant(s) to participate in all camp activities on and off site. *

I agree

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