Laurel Historical Society Rube Goldberg Camp 2022 Registration and Permission Form

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Parent/Guardian should complete and submit this form. Registration is by first-come, first-served and camp will be limited to campers entering grades 3-5 in the fall.

Registration will not be considered complete unless each field is correctly filled out and permission is given by the parent or guardian.

Child's First Name *

Child's Last Name *

Child's Date of Birth *

YYYY

Sex/Gender *

Female

Male

Prefer not to say

Other:

Grade child will enter in the fall *

Only children entering grades 3-5 are allowed to participate in the Rube Goldberg Camp.

Grade 3

Grade 4

Grade 5

School Name *

Parent/Guardian's First Name *

Parent/Guardian's Last Name *

Parent/Guardian's Phone Number *

Parent/Guardian's Email Address *

Home Address *

Are you a member of LHS? *

Yes

Have you attended summer camp at LHS before? *

Yes

PARENT/GUARDIAN ACCEPTANCE OF PROGRAM GUIDELINES

I understand that the student selection will be made in order of registration and that each class will be limited to no more than thirty (30) students.

I give permission for my child to participate in the Rube Goldberg Camp program and my signature below indicates my acceptance of the following:

My child must:
-Arrive promptly at assigned time and follow virtual instruction.
-Notify the host if child is unable to participate.

I understand that while both the camp and home activities are designed to be safe, neither the host site, nor the teacher, nor the volunteer warrants or can guarantee that an accident will not occur In consideration for my child’s participation in the Rube Goldberg Camp program, I agree not to initiate any action against the host site, teacher, volunteer, and to forever refrain from instituting any claims, causes of action, suits or proceedings of any kind for any injury or damage resulting from participation in the Rube Goldberg Camp program or from use of the take-home materials after the conclusion of the program.

I understand that my child may be photographed or filmed as part of a video to be used by the host site for publicity and promotion of the Rube Goldberg Camp program, on the website, or in social media. In addition, newspapers and television stations may take photographs or film or your child as part of their reporting. Please contact the Laurel Historical Society to directly opt out of the photography/video permission.

I consent to and authorize the use and reproduction by the host site or anyone authorized by the host site, including the media, of any and all videotapes, still pictures, correspondence and sound of my child’s voice for no monetary compensation. The videotapes, photographs and negatives shall become the sole property of the host site, which reserves the right to reproduce or distribute any published materials or any other publication published under the auspices of the host site and to license these rights to others.

I hereby understand and consent to the conditions of the Rube Goldberg Camp program as described above.

Parent/Guardian Name *

By filling in this field, you agree to sign this form as your signature.

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