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Date ______________________________________________________________________________
Camper Name ______________________________________________________________________
Camper Medical Conditions or Medications _______________________________________________
__________________________________________________________________________________
Camper Cell Phone Number ___________________________________________________________
Parent Names & Phone Number(s) ______________________________________________________
__________________________________________________________________________________
Emergency Contact __________________________________________________________________
Relationship of Contact to Camper ______________________________________________________
Contact Phone Number(s) _____________________________________________________________
I have a tent and will bring it and set it up ________________________________________________
Parent Signature (s) __________________________________________________________________
Camper Signature ___________________________________________________________________
The parent signing above, on behalf of her/his minor child/ward, does hereby release, discharge and
covenant to hold harmless Ma Ye n k a J i r a s e k a n d E d w a r d L i s s f r o m a n y a n d a l l c l a i m s , c a u s e s o f a c t i o n , a n d l i a b i l i t y o f a n y k i n d o r n a t u r e , a r i s i n g o u t o f , d i r e c t l y o r i n d i r e c t l y , t h e c h i l d s / w a r d s p a r t i c i p a t i o n i n t h i s e v e n t . W h i c h r e a l l y j u s t m e a n s p l e a s e d o n t s u e u s . W e w a n t o u r k i d s t o h a v e a g o o d , b u t s a f e , t i m e .
T h e p a r e n t s i g n i n g a b o v e a l s o g i v e s p e r m i s s i o n f o r M a Ye n k a J i r a s e k , E d w a r d L i s s , a n d a n y o f t h e p a r e n t v o l u n t e e r s a t W a t e r T o w e r P l a c e o r J a z z F e s t , t o m a k e e m e r g e n c y m e d i c a l d e c i s i o n s s h o u l d t h e n e e d a r i s e . ( S e e i nsurance card note below.)
4th Year Marwood Parents need to sign below as well, giving permission to Brenda and Michael DeJong to make emergency medical decisions should the need arise, as well as holding them harmless from any and all claims, causes of action, and liability of any kind or nature, arising out of, directly or indirectly, the childs / wards participation in this event. Which really just means please dont sue them. They too want our kids to have a good, but safe, time.
4th YR Parent Signature____________________________________________________
4th YR Camper Signature___________________________________________________
IMPORTANT - PARENTS: Please send an insurance card with your camper(s) to keep in their wallet or purse should the need for medical attention arise.
You can fax this right away to (708) 660-1742 so we have it on file from the beginning.
But if you don't, bring it with you on Friday! DON'T FORGET!
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