Primary Day Camp Registration

Camper Information

One form per camper

Parent/Guardian Information

Emergency Contact Information

Participation & Release

While we make every effort to provide a safe and pleasant environment for every camper who attends Camp Assurance, we do require that this participation agreement be read, filled out, signed, and dated by all campers (or their parent/guardian if under the age of 18) who wish to participate in activities at Camp Assurance.

Although Camp Assurance has taken reasonable steps to provide equipment and skilled employees so you or your child can participate in activities for which you/he/she may not be skilled in, we do remind you that these activities are not without risk. Certain risks cannot be eliminated due to our camp’s rural setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about inherent risks.

With full knowledge, I accept full responsibility for any injury or accident that may occur to myself or my child while participating in Camp Assurance activities. I give permission for myself or my child to attend and participate in activities that occur at Camp Assurance. These activities may include, but are not limited to, swimming, canoeing, zipline, archery, riflery, paintball, strenuous activities, and competitive games.

 I understand that for promotional or marketing purposes, Camp Assurance reserves the right to use any audio, video, and/or photography of guests or campers participating at Camp Assurance facilities.

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Camp Assurance, its officers, board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my or my child’s participation in any activity occurring at Camp Assurance. This release does not apply to intentional and/or willful acts of misconduct by Camp Assurance or any of its officers, board, agents or employees. By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and/or my child may be found by a court of law to have waived any right to maintain a lawsuit against Camp Assurance on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound by its terms. 

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Medical Information

Medical Agreement

I give permission for myself or my child to attend camp at Camp Assurance. I understand that my personal insurance will provide primary coverage for medical aid and that Camp Assurance will provide excess coverage. I also understand that if myself or my child must be sent home because of disciplinary or other problems, I will assume the additional transportation cost. IN CASE OF MEDICAL EMERGENCY, I hereby give permission to the physician selected by the camp director or his agent to hospitalize, secure proper treatment for, and order injection, x-ray, anesthesia, or surgery for myself or my child as named previously.  (Please notify the camp if this child has been exposed to any communicable disease during the two weeks prior to camp attendance.)  

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.