Vigo County Junior Fire Camp

Camper Information

Camper's First Name:

Camper's Last Name:

Address:

City:

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Camper's Birthday: Month 123456789101112 Day 12345678910111213141516171819202122232425262728293031 Year 1998199920002001

Camper's Shirt Size: Youth L Adult S Adult M Adult L Adult XL

Camper's School: Chauncey Rose Middle School Honey Creek Middle School Otter Creek Middle School Sarah Scott Middle School West Vigo Middle School Woodrow Wilson Middle School

Parent Information

Parent's First Name:

Parent's Last Name:

Parent's Email Address:

Confirm Email:

Parent's Phone Number: - -

Type jrfirecamp in the box:

Special Needs:

By submitting this form I verifty that I am the parent/guardian of the child listed above, a minor child applying to participate in Junior Fire Camp, sponsored by the Vigo County Agencies of Emergency Response (VCAER). For my child and myself I acknowledge, agree and understand that:

1. Voluntarily and of my own free will, I agree to allow my child to participate in the Junior Fire Camp. I understand the deadline for applications is July 1, 2011 and the fee for the camp is $20.00. I understand that registration is not confirmed until the camp fee and the Parent Signature Form (information emailed upon registration) are recieved by the Junior Fire Camp staff.
2. I understand that the participant may be involved in certain physical activities and there are certain potential risks and hazards involved in participation in Junior Fire Camp that could result in stress, injury or death to participant(s), including, but not limited to those hazards associated with natural conditions, equipment, staff and other participant’s actions.
3. I hereby approve my child’s participation in all aspects of Junior Fire Camp.
4. I understand that I will need to provide daily transportation for my child to and from the camp site.
5. To the best of my knowledge, there are no physical or other conditions, which would restrict my child’s participation in Junior Fire Camp. I further consent to any emergency medical treatment for my child deemed to be required by medical professionals, and will remain responsible for all costs incurred for such care.
6. I voluntarily elect to accept and assume all risk of injury incurred or suffered by my child while participating in Junior Fire Camp, including all activities related thereto.
7. I release, discharge and agree not to hold liable the Vigo County Agencies of Emergency Response (VCAER), and/or any of these agencies departments, officers, members, employees, or any person or entity connected with these agencies for any claim, damages, costs, or cause of action which my child or I may now, or in the future, have as a result of injuries or damages sustained or incurred by my child from whatever cause including but not limited to the negligence, breach of contract or wrongful conduct of the parties hereby released, and shall indemnify and hold harmless the Vigo County Agencies of Emergency Response (VCAER) and/or any of these agencies departments, officers, members, employees, or any person or entity connected with these agencies for any and all claims or damages of any kind what so ever which may result from the activities for which my permission has been given.