2023 Summer Camp Registration Form

"*" indicates required fields

Week(s) of attendance*

Please indicate what week(s) of camp your child will be attending. Camps are for ages 7-12, and run from 9:00 to 12:30 daily.

Week 2 (July 17-21)

Week 3 (July 24-28)

Week 4 (July 31-August 4)

Camper Information

Camper's Name*

First Last

Birth Date*

Address

Street/PO Box Town/City State Zip Code

Home Phone

Parent/Guardian # 1

Parent/Guardian #1 Name*

First Last

Address

Street/PO Box Town/City State Zip Code

Home Phone

Cell Phone

Place of Employment

Work Phone

What is the best way to reach Parent/Guardian #1?

Send all email communication to Parent/Guardian #1?

Yes

Parent/Guardian # 2

Parent/Guardian #2 Name

First Last

Address

Street/PO Box Town/City State Zip Code

Home Phone

Cell Phone

What is the best way to reach Parent/Guardian #2?

Send all email communication to Parent/Guardian #2?

Yes

Emergency Contacts

(in case a parent/guardian as listed above cannot be reached)

Name

Phone

Relationship to Child

Name

Phone

Relationship to Child

Names of persons who are permitted to remove the child from the program:

Person 1

Person 2

Person 3

*PLEASE NOTE: We must be able to contact someone on this form at any time your child is in our care. Please inform us in writing if any of your contact information changes or if you wish to add or remove anyone from the pick-up list.

Medical Information

Name of Physician

First Last

Address

Street Address Town/City State Zip Code

Phone

Health Insurance Carrier

ID #

Group #

I hereby give my consent, in the event of a medical emergency when I cannot be contacted, for Historical Society staff to obtain whatever treatment may be deemed necessary for:

Date of Birth

Your child's name

This authorization includes my consent for the above-named child to receive treatment by a physician in any hospital emergency department. I hereby give my authorization for emergency medical treatment as outlined above.

Date of last tetanus shot

Does your child self-administer any medications such as an inhaler or epi-pen?

All medication must be given to the Camp Director and come in original bottle with the name of child, medication, dosage, and doctor’s name.

Please list any medication your child will be taking at camp.

Allergies

(Please check all that apply)

Animals

Penicillin

Serious ivy, oak, sumac

Foods

Insect bites, stings

Medications

Other

Does your child have any medical conditions we should be aware of?

Also include anything about your child’s health that will help the Historical Society staff to better understand and work with your child, such as hearing / vision problems, physical needs or behavioral issues (Please attach letter if necessary.)

Additional Medical Information

Optional letter explaining your child’s medical information in more detail.

Max. file size: 50 MB.

Disabilities or Physical Restrictions

Please describe any disabilities or physical restrictions of which you want us to be aware and any reasonable adaptations or accommodations that are requested

Is there anything we should know about your child to ensure their success in our program?

Consent and Authorization

I approve of my child using his/her own:

Bug Spray*

Yes

Sun Screen*

Yes

2023 Summer Camp Waivers

CHILD RELEASE FORM AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT

IN CONSIDERATION of being permitted to utilize the facilities, services and programs of the Camden-Rockport Historical Society (or for my children to so participate) for any purpose, including, but not limited to observation or use of facilities or equipment, or participation in any off-site program affiliated with the Camden-Rockport Historical Society the undersigned, for himself or herself and any personal representatives, heirs, and next of kin, hereby acknowledges, agrees and represents that he or she has, or immediately upon entering or participating will, inspect and carefully consider such premises and facilities or the affiliated program. It is further warranted that such entry into the Camden-Rockport Historical Society for observation or use of any facilities or equipment or participation in such affiliated program constitutes in acknowledgement that such premises and all facilities and equipment thereon and such affiliated program have been inspected and carefully considered and that the undersigned finds and accepts same as being safe and reasonably suited for the purpose of such observation, use or participation.

THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING:

THE UNDERSIGNED ON HIS OR HER BEHALF AND BEHALF OF SUCH CHILDREN, HEREBY RELEASES, WAIVERS, DISCHARGES AND CONVENANTS NOT TO SUE THE Camden-Rockport Historical Society , its directors, officers, employees and agents (hereinafter referred to as “releases”) from all liability to the undersigned, or such children and all his personal representatives, assigns, heirs, and next of kin for any loss or damages, and any claim or demands therefore on account of injury to the person or property resulting in death of the undersigned or such children whether caused by negligence of the releases or otherwise while the undersigned or such children, is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the Camden-Rockport Historical Society .
THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the releasees and each of them from any loss, liability, damage, or cost they may incur due to the presence of the undersigned or such children in, upon or about the Camden-Rockport Historical Society premises or in any way observing or using any facilities or equipment of the Camden-Rockport Historical Society or participating in any program affiliated with the Camden-Rockport Historical Society whether caused by the negligence or of the releases otherwise.
THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR PROPERTY DAMAGE to the undersigned or such children due to negligence of releasee or otherwise while in, about or upon the premises of the Camden-Rockport Historical Society and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the Camden-Rockport Historical Society.
THE UNDERSIGNED further agrees that the RELEASE, WAIVER AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as permitted by the law of the State of Maine and that if any portion thereof is held invalid, it is agreed that the balance shall continue in full legal force and effect.
THE UNDERSIGNED HAS READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT, and further agrees that no oral representations, statements or inducement apart from foregoing written agreement have been made.

I HAVE READ THIS RELEASE

Date

Signature

Camden-Rockport Historical Society Photo Release

I HAVE READ THIS RELEASE

I hereby give the Camden-Rockport Historical Society and all persons and corporations acting with its permissions or upon its authority, including the photographer, the absolute right and permission to take, copyright, use and publish photographs, videos, or other digital media (“photo”) of or concerning the camper named above for the purposes of Camden-Rockport Historical Society art, advertising, education, promotion, or for any other purpose consistent with the Camden-Rockport Historical Society mission. I agree that the photo becomes the exclusive property of the Camden-Rockport Historical Society and I waive all rights thereto. I waive all rights to inspect and/or approve any printed matter that may be used in conjunction with the photograph and the use to which it may be applied.

Date

Signature

2023 Camp Fee Payment and Cancellation/Change Policy Agreement

CAMP PAYMENT METHODS:

Please select one of the camp payment options below. Registration cannot be confirmed until the entire completed registration packet is returned and payment arrangements are confirmed.

All camp programs must be paid in full at the time of registration. Due to the popularity of our camp, we must enforce a strict cancellation policy. Refunds will be given if the parent/guardian cancels two weeks or more prior to the camp week start date. If a two week notice is not provided, no refund or credit will be issued. We are dedicated to working with all families and are committed to ensuring children enjoy their summer camp experience, please contact us at 207-322-1971 with questions.

Payment Method*

Pay in full online

Pay by Check

Amount to Pay*

Camp cost is $200 per week.

Payment Method

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Please make checks out to Camden-Rockport Historical Society with “Summer Camp” in the memo field.

FINANCIAL ASSISTANCE: If you need financial assistance / payment arrangements, please contact us

Change Policy

Fees are based on enrollment, not attendance. Our desire is to enable every child who wants to come to camp the opportunity to do so. Please contact us immediately if you need to change your scheduled week(s) of camp.

I have read or had read to me the Fee /Change Policy Agreement and understand and accept its terms. I understand that fees are based on enrollment and not attendance.

Signature*

Print Name*

Date*

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Comments

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Historical clothing such as tricorn hats and bonnets and aprons will be provided ; however, if your child has a Colonial-era outfit (from the 1770s American Revolution) they are welcome to bring their own!

Sneakers or other comfortable walking shoes are required. No sandals or flip-flops please! Bring a labeled water bottle and a snack. Please ensure kids have a good breakfast before they arrive.