The Coleman Company joins Bass Pro Shop and the Quail & Upland Wildlife Federation to help sponsor the Kansas Wildlife Federation’s Day Camp for boys & girls (10-12 years old) at TimberRidge on June 12th, 2013.
The Application, the Johnson County Liability Waiver and the Health & Participation forms below must be signed and mailed to Ted Beringer (cell 913-484-0109) at the address below no later than Friday, June 7th or brought to TimberRidge on June 12th.
Application for the Kansas Wildlife Federation Day Camp
at TimberRidge Adventure Center, June 12th, 2013,
for boys & girls (10-12 years old)
The application fee is $25.00. Please return this form with a check made payable to
“Ted Beringer, Kansas Wildlife Federation” to the following address:
Ted Beringer, Kansas Wildlife Federation
15313 W. 80th Terrace
Lenexa, KS 66219
Please send the application fee no later than May 21st. A receipt will be sent to your email address. A full refund will be returned to you if I receive your notice of cancellation on June 10th or before. However, the fee will not be reduced if your child is late for the event or must depart early. The Day Camp begins promptly at 9 am.
Please provide the following information:
Name of parent or guardian attesting that the boy or girl is 10-12 years old: ________________________________________________________________
Phone number(s) of parent or guardian: ________________________________________________________________
Name of boy: ________________________________________________________________
Name of girl: ________________________________________________________________
The TimberRidge Adventure Center is located at:
12300 S. Homestead Ln, Olathe, KS 66061
Johnson County Park and Recreation Waiver Statement
WAIVER STATEMENT: The undersigned states that he/she understands that the Johnson County Park and Recreation District is not and shall not be responsible for or liable for any illness, or injury to person or damage to property resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park and Recreation District, it’s employees, agents and representatives from any and all claims of any kind that the participant, or the undersigned or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program. NOTICE: By enrolling in this program you hereby acknowledge the Johnson County Park and Recreation District can and may photograph and/or video tape program participants and then use such images, without payment or any other consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purpose. (Registration is invalid without signature.)
I have read and I understand the Waiver Statement
X ___________________________________________________ X ___________________________________________
Signature of Parent or Guardian Participant Name
This Waiver Statement is for the summer of 2013, 5/28/2013-8/2/2013
Health and Participation Form
Group: Kansas Wildlife Federation Day Camp at TimberRidge Date: 6/12/2013
Attendee’s Name: _______________________________________________
Health
List below any physical condition the doctor, EMT, nurse, TimberRidge staff or Kansas Wildlife Federation staff should be aware of. (All information will be kept confidential.) Check conditions present and list any pertinent information.
__ insect stings__ diabetes__ heart condition__ ear infection
__ fainting spells__ headaches__ allergies (explain)___________________________
__ asthma
______________________________________________________________________________________________
allergic to any drugs (please list) ____________________________________________________________________
_______________________________________________________________________________________________
prescribed medicines presently taking ________________________________________________________________
_______________________________________________________________________________________________
date of last tetanus immunization ____________________________________________________________________
other conditions __________________________________________________________________________________
Participation
TimberRidge Adventure Center staff is trained to provide the safest activities possible. I understand the campers will be closely supervised and agree that the supervisors, the Kansas Wildlife Federation and its representatives are not responsible in case of injury or illness. I further understand that first aid will be available and that should a serious injury or illness occur, medical or hospital care will be provided. I realize the supervisors will notify me in case of serious injury or illness. However, should they be unable to contact me, Thereby grant my permission and consent for emergency medical or surgical care to be given, as determined necessary by a licensed physician.
Parent or Guardian’s Signature ______________________________________ Date ______________________
I specifically agree to hold the Kansas Wildlife Federation and its representatives harmless as to any claim for damages for any accident or injury of any kind resulting from the participation of my minor ward in the Kansas Wildlife Federation Day Camp activities at TimberRidge, and this “hold harmless guarantee” is specifically granted in consideration of the services by TimberRidge Adventure Center.
Parent or Guardian’s Signature ______________________________________ Date______________________________
Address ___________________________________________________________________________________________
In case of an Emergency please notify: ___________________________________________________________________
Day Phone #-________________________________________________________
Evening Phone #- ________________________________________________________________
Registration is complete after form is signed.
