DISCOVER A CIVILIZATION THIS SUMMER!
2011 Registration Form
back to City Camp
In addition to completing this form, you must pay for your registration online through the
City Camp Google Checkout system - click here for link.
Your registration will not be confirmed until full payment is made and the registration form is completed and received by City Camp.
Confirmation will be sent by email once registration is complete.
Name: Gender: BOY GIRL
T shirt size (circle one): child S M L adult S M L XL
Age: Birthday: Grade Entering Fall 2011:
Home Street Address:
City: State: Zip:
Home Phone: Alternate Phone:
Parent Name: Contact email:
How did you first hear about City Camp?
Emergency Contact Name:
Emergency Contact Phone: Alternate Phone:
Medical Insurance Company: Insurance Policy #:
Doctor’s Name: Doctor’s Phone:
Special Medical Needs:
Medications:
Option 1: I authorize City Camp to release my child to get home however he or she chooses, including walking, riding a bicycle, taking public transit, or leaving with an adult.
Option 2: I authorize City Camp to release my child ONLY to an adult who comes to pick them up, but the adult is not required to show photo ID.
Option 3: I authorize City Camp to release my child ONLY to the adults listed below, who are required to show photo ID at time of pick up (including myself):
Myself:
Additional adults authorized to pick up my child:
1. ELIGIBLE AGE
By registering a participant for City Camp, I certify that the participant is between the ages of 5 and 12 years old and will be entering a grade level at school in the fall after the summer of camp that is, or is the equivalent of, first grade through seventh grade in the American school system. I certify that I am not registering any children who have not yet completed one year of Kindergarten nor have already completed any amount of time in the seventh grade.
2. INFORMED CONSENT
I understand that there are inherent risks involved in the City Camp programs and activities in which my child will be participating, including, but not limited to, playing with other children, playing on recreational equipment, walking through urban areas, taking multiple forms of public transit, visiting urban institutions, and participating in activities organized by other institutions that have their own procedures, rules and hazards. I also understand that although City Camp gives highest priority to providing campers a safe, caring and enjoyable environment and has taken safety measures to minimize risks, City Camp cannot ensure nor guarantee that the participants, equipment, premises and/or activities encountered while attending City Camp will be free of hazards, accidents and/or injuries. I certify that I have familiarized myself with the program and activities of City Camp in which my child will be participating and I acknowledge that my child’s participation is completely voluntary. I also recognize that it is my responsibility as a parent to instruct my child in the importance of knowing and abiding by City Camp’s rules, regulations and procedures for the safety and enjoyment of the entire City Camp community.
3. CODE OF CONDUCT AGREEMENT
City Camp gives highest priority to providing a safe, caring, and enjoyable environment for everyone in the City Camp community. To help achieve this goal, the camper registering for City Camp agrees to demonstrate respect for other campers, counselors, and the places he or she visits, follow program rules, possess a positive attitude, use common sense and exhibit good behavior as a member who makes positive contributions to City Camp. The camper understands that this agreement prohibits fighting, hitting, teasing, throwing objects, dishonesty, inappropriately loudness, inappropriate language, separating from the group, destruction of property, and using drugs, tobacco or alcohol. He or she also understands that violating this agreement will result in a three-step process:
1) A member of the program staff will discuss the violation with the camper and notify his or her parents, explaining the violation;
2) If the camper violates the agreement again during any given session, he or she will be dismissed from the program for the day, and program staff will notify his or her parents to come pick the camper up immediately;
3) If the camper violates the agreement a third time during any given session, program staff will notify his or her parents to come pick the camper up and he or she will be terminated from the entire session, forfeiting all registration fees without refund.
4. ON TIME DROP-OFF AND PICK-UP AGREEMENT
To maintain the quality of the City Camp experience, it is essential that campers arrive at camp and go home on time every day. As the parent, I understand that it is my responsibility to arrange for my child to be delivered to and picked up from City Camp on time. I further understand that for every ten minutes my child is not picked up after the end of his or her time at camp, I, as the parent, will owe City Camp $10.00.
5. PUBLICITY PERMISSION
I grant permission to City Camp to use images of, quotations from, and/or work produced by my child for any and all publicity purposes, including published material, video, websites, and other media.
6. MEDICAL ATTENTION
If a camper has a medical emergency, the City Camp policy is to contact the camper’s parents and/or the person listed as the camper’s emergency contact. In addition, I grant permission to City Camp to administer first aid, CPR, or any other form of emergency medical care to my child if needed, and to contact his or her doctor or call for an ambulance if necessary. I also understand that City Camp will not be held financially responsible for the cost of medical care nor hospitalization for my child.
7. RELEASE AND INDEMNITY
On behalf of myself, the registrant, and the registrant’s parents or guardians, I hereby release and discharge City Camp from all claims made on behalf of myself, the registrant, and the registrant’s parents or guardians (and the executors, heirs, administrators, and assigns of all such parties) against all claims, demands, judgments, and costs (including reasonable attorneys' fees) arising out of or relating to the registrant’s participation in City Camp. Further, I agree to indemnify and hold City Camp harmless from all such claims, demands, judgments, and costs (including reasonable attorneys' fees) made by any third party arising out of or relating to the registrant’s participation in City Camp.
8. GENERAL INFORMATION
These Terms and Conditions constitute an agreement between myself, the registrant, the registrant’s parents or guardians and City Camp (“The Parties”) and govern participation in the City Camp, superceding any prior agreements. The Terms and Conditions and the relationship between The Parties shall be governed by the laws of the State of California without regard to its conflict of law provisions. The Parties agree to submit to the personal and exclusive jurisdiction of the courts located within Alameda County, California. The failure of City Camp to exercise or enforce any right or provision of the Terms and Conditions shall not constitute a waiver of such right or provision. If any provision of the Terms and Conditions is found by a court of competent jurisdiction to be invalid, The Parties nevertheless agree that the court should endeavor to give effect to The Parties' intentions as reflected in the provision, and the other provisions of the Terms and Conditions remain in full force and effect. The section titles in the Terms and Conditions are for convenience only and have no legal or contractual effect.
I accept the terms of this waiver: Date:
Please
send this registration form to:
City
Camp, 1429 Oxford St., Berkeley, CA, 94709