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Emergency Contacts & Child Pick-Up

Include all authorized individuals to be contacted if unable to reach parents. Authorized person will be required to show proof of identification when taking child home from camp. Your
child will not be released to anyone except the individuals listed.

1. Name ____________________________________________ Relationship ____________________ Cell ____________________

Emergency Contact Authorized for Camp Pick Up

2. Name ____________________________________________ Relationship ____________________ Cell ____________________

Emergency Contact Authorized for Camp Pick Up

3. Name ____________________________________________ Relationship ____________________ Cell ____________________

Emergency Contact Authorized for Camp Pick Up

Medical Consent & Waiver

1. Does your child have allergies? Yes ______ No ______ If “Yes”, please list allergies __________________________________

__________________________________________________________________ EpiPen ________ Other ________

2. Does your child require medication during program hours? Yes ______ No ______ (If “Yes”, complete Medication Dispensing Form.)

I do hereby give my permission and/or consent to the personnel of the Niles Park District camp staff to secure and authorize such emergency medical care and/or treatment as my child
(above named) might require while under the supervision of said day camp personnel. I also agree to pay all costs and fees contingent on any emergency medical treatment of my child
as secured or authorized under this consent.

WALK PERMISSION Camper listed under counselor supervision has my permission to take walks to local parks under proper supervision of camp personnel.

WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK
Please read this form carefully and be aware that in signing up and participating in these programs/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries,
damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services/vehicle
operation, when provided).

I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of
severity, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of
participating in all these programs/activities against the Niles Park District, including its officials, agents, volunteers and employees (here-in after collectively referred as “District”).
I do hereby fully release and forever discharge the District from any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out
of, connected with, or in any way associated with these programs/activities.

I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims. If registering online or via fax, your online or facsimile signature shall substitute
for and have the same legal effect as an original form signature.
Photos are periodically taken of participants in a class, during a special event or at the District’s parks. Please be aware that these photos are for Park District use only and may be used in the District’s publications.

I have read and fully understand the above important, warning or risk, assumption of risk and waiver and release of all claims.

Parent/Guardian Signature Date
PARTICIPATION WILL BE DENIED if the signature of adult participant or parent/guardian and date are not on this waiver.
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