Child's Name: Theodore Whitman   Summer Camp Location: Lake Central (Kolling)
Birth Date: May 26, 2017 Nickname: Theo Gender: Male Start Date: June 2, 2026 Days Attending: Monday, Tuesday, Days Will Vary Shirt Size: Child Medium Grade: [323]
School attending this fall?: Watson Grade this fall?: 4th Attend TAC During the Year?: Yes
Allergies:

Allergy tamiflu

Parent Guardian Name 1: Tressa Whitman Parent Guardian Name 2: Joseph Whitman Address: 2833 Whisper Ct City: Schererville State: IN Zip: 46375 Email: tlwhitm@gmail.com Primary Phone: 2196789584 Secondary Phone: 2199029444
Denied Pickup Name 1: Relationship: Primary Phone: Denied Pickup Name 2: Relationship: Primary Phone:
Emergency Pickup Name 1: Tressa Whitman Relationship: Mother Primary Phone: 2196789584 Secondary Phone: 2199029444
Emergency Pickup Name 2: Joseph Whitman Relationship: Father Primary Phone: 2199029444 Secondary Phone: 2196786584
Emergency Pickup Name 3: Rose Massaro Relationship: Grandma Primary Phone: 2196789375 Secondary Phone: 2196780557
Emergency Pickup Question 1: Name of dog Answer 1: Maple
Emergency Pickup Question 2: Mother’s maiden name Answer 2: Massaro
Paperless Billing?: Yes Billing Frequency: Hourly
Parent Release

In consideration of the services to be provided by The Adventure Club, Inc., and for other good and valuable consideration, the undersigned, for myself and for my minor child, and any and all family members, heirs, representatives, executors, administrators, and assigns of myself or of my minor child, hereby accepts full responsibility and assumes all risk, for my minor child’s use of any and all apparatuses, appliances, facilities, privileges or services, of any nature, which is/are owned, operated or provided by The Adventure Club, Inc. While engaging in any contact, game, function, exercise, competition or any other activity operating, organized, arranged, or sponsored by The Adventure Club, Inc. either on or off their premises, my minor child shall do so at his or her own risk.

I hereby release and hold forever harmless The Adventure Club, Inc., its owners, employees, representatives, and agents (collectively, “the releases”), and each of them, from any and all losses, claims, injuries, damages, or liability of any kind, sustained or incurred by us resulting therefrom, whether caused by the negligence of the releases or otherwise. I specifically agree to indemnify and hold harmless The Adventure Club, Inc., its owners, employees, representatives, and agents as to any loss, cost, claim, injury, damage or liability, sustained or incurred by using the facilities, equipment, or services, of The Adventure Club, Inc., which is caused by an act or omission, whether negligent or otherwise, of an employee, representative, or agent of The Adventure Club, Inc.

I understand/acknowledge that it is my responsibility to ensure that my minor child participates only in those activities for which he/she has the required physical conditioning. My signature below indicates that I have carefully read and freely signed this waiver, and constitutes my full acceptance of this waiver.

I understand that in an effort to prevent any potential conflict of interest, childcare outside TAC hours by TAC staff members is discouraged. However, should I hire TAC staff, it must be outside the TAC premises and with the understanding that such arrangements and payments for services are solely between me and the member. TAC does not sanction the arrangements, and I agree to hold TAC harmless from any such arrangement. If a center staff member chooses to baby-sit for an enrolled child, the Site staff member and I must request and sign a Liability Release Form to be kept in the child’s file.

Thank you for enrolling your child at The Adventure Club. It is our mission to provide a before and after school program that is an Enriching, Inspiring, Educating and Exciting place for your child to learn and grow while meeting the childcare needs of our parents, the school and communities we serve.

Thank you for the opportunity to be a part of your child’s life.

Signature:

Parent Handbook

I have received, read, and agree to abide by the Parent Handbook.

Signature:

Walking Trips

I give permission for my child to leave the Site for outdoor fitness and educational purposes, with the understanding that my child will be accompanied by TAC staff and under supervision at all times.

Signature:

Playground / Water

I give permission for TAC to include my child in supervised playground and water activities. My child has my permission to use all the play equipment and take part in all TAC activities.

Signature:

Transportation

I hereby grant permission for my child to participate in and be transported by commercial transportation companies while under staff supervision at all times for field trips and other TAC sponsored activities. I understand that children not attending TAC fieldtrips will remain on-site with TAC staff.

Signature:

Sunscreen

I understand that TAC is not responsible for any injuries that may result from the sun. I give permission for my child to apply/wear SPF 30 sunscreen that I supply.

Signature:

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