Summer Camp Application - Rohnert Park Animal Services

Summer 2023

Camper's Name*

First Last

Preferred Name - If different from full name

Address*

Address City Zip Code

Phone

T-Shirt Size*

School*

Grade in 2023-24 School Year*

Parent Information

Name(s)*

Email*

Primary Phone*

Secondary Phone

Emergency Contact

Name (Alternate to Parent)

Phone

Release Authorization - Please list anyone else who is authorized to pick up your child. Include their name, relationship, and phone number. Staff may ask for a California Driver License or ID before the child is released to these individuals.

Camp Information

Which camp session are you applying for?*

Are you able to attend all 5 days of this session?*

How did you hear about this camp?*

If there is a friend or sibling that you want to attend with, what is their name?

If you've attended this camp before, when was that?

If you currently have pets in your household, describe their breed, age, sex - are they fixed?, and whether they're mostly indoors or outdoors.

Health Information

Describe any food, medication, insect bite or sting, or other allergies that we should be aware of. For life-threatening allergies, please contact our office at 707-584-3057 at least one week before the start of camp to discuss an Emergency Action Plan.

Describe any behavioral, emotional, physical, or mental health concerns that we should be aware of. Any learning challenges we should know about?

Describe any camp activities from which your child should be exempted for health or other reasons.

Describe any other health related information camp staff should be aware of.

Camper's Medical Insurance Carrier*

Group/Individual Medical Policy #*

Physician Name

Physician Phone*

Waiver and Consent

Photo Release*

I understand that staff may take pictures of my child during camp for promotional use in City of Rohnert Park digital or print promotional materials without compensation, notification, or approval rights. All photos will remain property of the City of Rohnert Park.

Liability Release*

In consideration of the acceptance of my child’s application for the Rohnert Park Animal Shelter’s Animal Camp Program, I hereby waive, release, and discharge any and all claims for damages for death, personal injury or property damage which I may have, or which may hereafter accrue to me, as a result of participation in said program. This release is intended to discharge in advance the City of Rohnert Park and the Animal Shelter League of RP, its officers, employees or agents from liability, unless the cause of the accident/loss is the sole negligence of the city, its officers, employees or agents. It is understood that there are risks associated with some recreational activities, transporting to fieldtrips and the handling of animals, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns.

Consent to Treat*

I hereby give my consent to have the above applicant treated by a physician or surgeon in case of sudden illness or injury while participating in the above event. It is understood that the City of Rohnert Park, the Animal Shelter League of RP and the Rohnert Park Animal Shelter provides no medical insurance for such treatment, and that the cost thereof will be at my expense. If a personal physician is listed on the camp application, every effort will be made to contact such physician. However, the location of the activity, or the nature of the illness/ injury may require the use of emergency medical personnel.

Refund Policy*

I understand that a full refund will be given if notice is received at least one week (7 days) in advance to the start date of the camp session. A refund, minus a $25 processing fee, will be given if notice is received at least by 5:00 p.m. of the Friday before the start date of the camp session. No refund will be given for cancellations after that time or for individual days missed.

Parental Consent*

I give my consent for the above applicant to participate in the Rohnert Park Animal Service’s Animal Camp Program, and I execute the above liability releases on their behalf.

Signature*

By checking this box and typing my name below, I am providing an authorized signature indicating that I have read and understood the foregoing and agree to all of the listed terms and conditions.

Name*

First Last

Date*