Summer Camp Application - Rohnert Park Animal Services

Camper Information

Name*

First Last

Preferred Name - If different from Name

Address*

Address City Zip Code

Phone

T-Shirt Size*

School*

Grade in 2021-22 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, whether they're neutered/spayed, and whether they're kept 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.

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.

COVID-19 Assumption of Risk*

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. While COVID-19 can cause mild symptoms in some individuals, it can lead to severe illness and even death in others. Adults over age 65 and people of any age with serious underlying medical conditions including, but not limited to, HIV, asthma and other respiratory conditions and pregnancy, may be a higher risk for more serious complications from COVID-19. The City of Rohnert Park ("City") has put in place preventative measures to reduce the spread of COVID-19; however, the City cannot guarantee that you or your child(ren) will not become infected with COVID-19 if they attend a recreation program. Furthermore, attending City recreation programs could increase your risk and your child(ren)'s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID19 by attending the Rohnert Park summer day camp and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by attending Rohnert Park summer day camp may result from the actions, omissions, or negligence of myself and others, including, but not limited to, City employees, volunteers, and other program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)'s participation in City programming ("Claims"). In consideration of participation in these programs, on my behalf, and on behalf of my children, I hereby agree to release, waive, covenant not to sue, discharge, indemnify and hold harmless the City and the Animal Shelter League, and their officers, employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses (including attorneys' fees) of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the City or the Animal Shelter League, and their employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any City program. I have carefully read the above, understand its contents and on behalf of myself, my heirs and assigns, agree to the terms contained herein.

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*