(street, city, state, zip code)

 (including area code)

 (check all that apply)

(check any that apply)

(name, phone number and relationship)

Please list the name, phone number, email address and how long you have known this person. Note: References may be contacted.  Please do not use family members.

Please list the name, phone number, email address and how long you have known this person.  Note: References may be contacted.  Please do not use family members.

Please list the name, phone number, email address and how long you have known this person.  Note: References may be contacted.  Please do not use family members.

I agree to following and understand that some infractions may result in immediate dismissal from camp. The use of tobacco products or smoking is not permitted on camp property.  The use, possession, or being under the influence of alcohol or illegal drugs is prohibited.  Possession of any type of weapon or firearm is prohibited.  All medications need to be turned in to the medical staff.  Permission from my supervisor will be required to leave camp when camp is in session. Clothing will be free of references to alcohol, drugs, sex, tobacco, vulgarity or violence and be modest in appearance.  The use of profanity, vulgarity or foul language is unacceptable.  Staff will enforce age appropriate camper curfews and adhere to a curfew of midnight.  Vehicles may be used for transportation needs for those with mobility problems and at no time should a camper or staff member be riding these without permission. Campers and staff are allowed only in the sleeping area to which they are assigned.  Activities are mandatory (flag, meals, etc.) and staff and campers will be on time.  All money and valuables should be deposited into the camp bank, any valuables left in sleeping areas or vehicles will not be the responsibility of Special Days.  All staff will maintain friendly, supportive and professional relationships with campers and staff.  Fraternization between staff and campers is inappropriate and cause for dismissal.  Special Days Camps will not tolerate harassment, discrimination or hazing in any form. Phones are for staff use only at a time approved by their supervisor and campers should only use a phone with approval from the camp director.  Under no circumstances is raiding allowed.  

I agree to take full responsibility  for my personal safety as it related to attending camp on the property of YMCA Camp Pendalouan.  I release YMCA Camp Pendalouan and Special Days Camps, their officers, their agents, employees and volunteers from any liability and injuries I may receive as a result of volunteering, participating in activities either at camp or off site and from any medical care provided by Special Days Camps.  Furthermore, I acknowledge it is my responsibility to have a personal heath care insurance policy and release YMCA Camp Pendalouan or Special Days Camps from any financial liability for injuries I may receive as a result of volunteering including but not limited to any health care or emergency services costs.

I hereby give Special Days Camps the right and permission to copyright, publish and/ or resell image likenesses of myself in which i may be included in whole or in part for any lawful purposes including internet publishing.  I wave any right I have to inspect and / or approve the finished product or the use to which it may be applied.  I release, discharge and agree to same from liability by virtue of any blurring, distortion, alteration, optical illusion or processing trending towards the completion of the finished product.