Camp Kid's Day Out Registration Form
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Email *
Camper's First & Last Name *
Which camp session(s) are you signing up for? *
Required
Camper's Birthdate *
MM
/
DD
/
YYYY
Allergies? If yes, please describe.  *
Does the camper have any dietary requirements? *
Current medications?  *
Medical conditions? If yes, please describe. *
Family Doctor: *
Family Doctor Office Phone:  *
Insurance ID number: *
Insurance Policy Holder:  *
Insurance Provider:  *
Insurance Provider Number: *
Additional information, requests, or notes. 
Please let us know if you would like your child to be grouped with anyone particular and we will do our best to accommodate. 
 *
Camper #2 (if applicable) - First & Last Name 
Which camp session(s) is camper #2 signing up for?
Camper #2 Birthdate: 
MM
/
DD
/
YYYY
Camper #2 Allergies? If yes, please describe. 
Camper #2 Dietary Requirements:
Camper #2: Current medications? 
Camper #2: Medical conditions? If yes, please describe.
Family Doctor (if different than camper #1)
Family Doctor Office Phone (if different than camper #1)
Insurance ID number (if different than camper #1)
Insurance Policy Holder (if different than camper #1)
Insurance Provider (if different than camper #1)
Insurance Provider Phone (if different than camper #1)
Additional information, notes, or requests for Camper #2. 
Please note if you would like your child to be grouped with anyone particular and we will do our best to accommodate. 
Parent/Guardian #1: First & Last Name *
Parent/Guardian #1: Relationship to Camper
 *
Parent/Guardian #1: Phone Number
 *
Parent/Guardian #1: email
Parent/Guardian #2: First & Last Name
Parent/Guardian #2: Relationship to Camper
Parent/Guardian #2: Phone Number
Parent/Guardian #2: email
Emergency Contact:  First & Last Name
(if different / additional to Parent/Guardian)
Emergency Contact:  Relationship to Camper
Emergency Contact:  Phone Number
Alternative Pick Ups (list all first & last names)
Sunscreen Waiver 
KDO Camp will spend time in the sun. By agreeing to this waiver, you are allowing our Camp Directors and Camp Coaches to re-apply sunscreen on your child throughout the week of camp. 
Photo Release Waiver
I grant permission to Kid's Day Out (KDO), its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at KDO for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium. I hereby release KDO and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Registration Fees 
Camper enrollment is confirmed when payment is received. The registration fee is due, two (2) weeks before the start of your camp session. Payment accepted via Venmo (@KidsDayOut), check, or cash.
Cancellation Fees
·       $100 cancellation fee if the session has not started
·       No refund if the session has started

Typing my First & Last name below acts as my signature and as my approval that I attest to the accuracy of the information I provided on this form and I agree to the waivers and fees outlined on this form for all campers I am registering. 
 *

Parent’s Camper Assumption of Risk & Waiver of Liability Agreement

I agree to allow my child to participate in the Kid’s Day Out Summer Camp (KDO) and affirm that my child’s participation is entirely voluntary. I also understand that participation in the KDO Summer Camp involves a risk of injury due to certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries, such as, but not limited to, the following: contact with other individuals playing; contact with the floor, walls, or equipment which are part of the playing area; strenuous exertions, quick movements, and changes of speed, which place stress on the cardiovascular, muscular, and skeletal systems; and muscular and skeletal stresses and strains due to strengthening and conditioning exercises. The specific risks vary from (1) minor injuries such as scratches, bruises and sprains, to (2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions, to (3) catastrophic injuries including paralysis and death. I understand that if I have questions about possible hazards, it is my responsibility to seek additional information from the KDO Summer Camp staff prior to signing this agreement. I also understand that, despite safety precautions, KDO cannot guarantee that my child will not be injured. I, as my child’s parent/guardian, agree to assume all these risks. I understand that the best way to make sure that my child remains safe and avoids injury is for my child to follow the rules, regulations and instructions of the staff of the KDO Summer Camp. My child and I are willing to and have assumed these risks. To minimize the risks, I have instructed my child to obey all the rules, regulations and instructions of the KDO Summer Camp. In consideration for permitting my child to participate in the KDO Summer Camp, I voluntarily agree, for myself, my heirs, executors, and administrators, to the following:

TO ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, OR PERSONAL INJURY, INCLUDING DEATH that may be sustained by my child or any loss or damage to property owned by my child as a result of training for or participating in the KDO Summer Camp.

TO RELEASE, WAIVE, HOLD HARMLESS, DISCHARGE, & AGREE NOT TO SUE the persons or entity responsible for administering the KDO Summer Camp, Cornerstone Church, or its trustees, officers, employees, agents, students, and staff from any and all liability, claims, actions, demands, expenses, attorneys’ fees, breach of contract actions, breach of statutory duty, or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might now have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by my child or me, or to any property belonging to my child or me, while training for or participating in the KDO Summer Camp.

TO AUTHORIZE THE STAFF OF THE KDO Summer Camp to act for me, according to their best judgment, in seeking or obtaining any emergency medical attention for my child. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care deemed advisable by the aforementioned physician in the exercise of his best judgment.  It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient but that none of the above treatment will be withheld if the undersigned cannot be reached.

I have no knowledge of physical impairment that would be affected by child’s participation in the KDO Summer Camp program, as outlined in the brochure/flyer/website.

Typing my First & Last name below acts as my signature and as my approval that I agree to the above information for all campers I am registering.

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