summer camp appliction

Child's name

sex Birthdate Age School

Email address

Mother/Guardian Cell

Buisness Name Work phone

Father/Guardian Cell

Buisness Name Work phone

Home Address Zip Phone

Sessions: Please check all that apply

#1 #2 #3 #4 *#5

#6 #7 #8 #9 #10 #11

* Closed Wednesday July 4th. week 5 Tue-Fri $100.00

Camp runs from 8:30-5:00pm. Extended care is available from 7:30-8:30 @ $10.00 per week and from 5:00-6:00pm @ $10.00 per week. Please note there is no late pick-up on Friday.

T-Shirt size:

AXL

MIDWEST SUMMER CAMP INFORMED CONSENT AND RELEASE FORM: BY SIGNING THIS FORM, I AGREE AND ACKNOWLEDGE I AM FAMILIAR WITH THE POLICIES OF THE SUMMER CAMP AND THE PHYSICAL ACTIVITIES FOR WHICH MY CHILDREN IS ENROLLED TO PARTICIPATE AND UNDERSTAND THAT THE AVTIVITIES MAY INCLUDE PHYSICAL CONTACT/STRENUOUS PHYSICAL EXERCISE AND COULD RESULT IN PERSONAL INJURY, KNOWING THESE RISKS, I HEREBY WAIVE AND RELEASE AND DISCHARGE MIDWEST SUMMER CAMP, IT’S EMPLOYEES, ASSOCIATED SPORTS CAMPS AND STATE OF MISSOURI FROM ALL CLAIMS, INJURIES, DAMAGES OR ACTIONS OF ANY KIND OR NATURE ARISING OUT OF MY SON/DAUGHTER’S PARTICIPATION IN THE SUMMER CAMP ACTIVITIES OR USE OF THE FACILITIES THAT MAY BE BROUGHT BY MYSELF AND ANYONE WHO MIGHT MAKE A CLAIM ON MY BEHALF ARISING OUT OF PARTICIPANTS ACTIVITIES, SERVICES OR EQUIPMENT PROVIDED BY MIDWEST, NOTWITHSTANDING THE NEGLIGANCE OF MIDWEST CAMPUS, IT’S TRUSTEES, OFFICERS, EMPLOYEES OR AGENTS. I CERTIFY THAT MY SON/DAUGHTER (NAME) HAS ACCIDENT INSURANCE COVERAGE. I HAVE READ AND I AGREE WITH THE TERMS AND CONDITIONS OF THE SUMMER CAMP AS IT RELATES TO MY SON/DAUGHTER AND CERTIFY THAT ALL INFORMATION ON THE ABOVE APPLICATION IS TRUE.

SIGNATURE DATE

PARENT/GUARDIAN

Please print the above application and attach your check or credit card information for your $25.00 per week deposit.

Check Number Amount $

Credit Card Information:

Name On Card

Card Number Expiration Date Security Code