Registration Form 2017 Wet and Wild Camp Registration This registration must be completed in its entirety to be accepted. Spaces at camp are limited, so registrations are accepted on a first-come-first-served basis. Registrations can be saved and returned to at a later time. Please note: Each camper must have their own application form completed. Siblings must be registered on separate forms for each child. Camper InformationName* Legal First Last Preferred First NameBirthday*Please select an age group*6-89-1112-14Age as of July 10, 2017*Sex*T-Shirt Size*YOUTH smallYOUTH mediumYOUTH largeADULT smallADULT mediumADULT largeADULT extra largeParent/Guardian InformationName* First Last Name First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Include area codeEmail*The majority of communication will be done via email, so please provide an email address you check regularly. Emergency ContactName* First Last Phone*Include area codeRelationship to Child*NameOptional Second Contact First Last PhoneInclude area codeRelationship to ChildPhotography Consent Form/Model Release For MinorsMedia Release Form*As parent or official guardian of the child whose name appears on this registration sheet, I hereby grant permission to Clemson University and the Greenville County Soil and Water Conservation District, its employees or representatives, to take and use: photographs, videotape and/or digital images of my child for use in promotional or educational materials as follows: printed publications or materials, electronic publications or presentations, websites. I agree that my child's name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Clemson University and Greenville County Soil and Water Conservation District. The selection of agree or disagree below represents my digital signature for this release form.Yes, I agree to the above conditions.No, I do NOT agree to the above conditions.Health and Medical HistoryDoes this child have any known allergies?*This includes food, medicine, plants, animals, insects, etc.YES, my child has known allergies.NO, my child does NOT have known allergies.List any known allergies here.Does the child experience or has he/she ever experience (or had special needs in) any of the following?Check all that apply. Asthma Attention Disorders (ADD, ADHD, etc.) Bleeding Disorder Diabetes Eating Disorders Fainting Spells Heart Condition Seizures/Convulsions Wears Contacts Other Please Describe/Explain Any Condition or Need Checked Above.Is this child currently taking any medication?*If answer is YES, please complete the Permission to Administer Medication information below.YES, my child takes medication.NO, my child does NOT take medication.Medication Name*Medication Dose*Time of Day/Frequency of Dose*Potential Side Effects (If Applicable)Prescribing Physician*Name, address, and phone numberDo you grant permission for my child to be administered his/her medication by a camp director?*YES, I grant permission.NO, I do NOT grant permission.Has this child undergone surgery or experienced any injury, illness, allergy, or change in health status any time during the last year? Is there any reason that participation in a program or activity should be restricted?*YES, my child has activity restrictions.NO, my child does NOT have activity restrictions.Please explain.*Does this child require special diet?*This includes vegetarian, dietary restrictions, dietary allergies, etc.Yes, my child has a restricted diet.NO, my child does NOT have a restricted diet.Please explain.*Is there any necessary, additional information staff should know in order to identify and provide appropriate supervision, support, and accommodations for this child?*This includes behavioral/physical/emotional disabilities, medication instructions, and/or special restrictions?YESNOPlease explain.*Parent Authorization and Permission to Treat*The above described health history is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities, excepted noted as by me and/or my child's physician. I hereby give permission to the medical personnel selected by the camp director to provide routine health care: to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the child whose name appears on this form.Yes, I agree to the above conditions.NO, I do NOT agree to the above conditions.Liability FormClemson University Parental Permission Form and Release of Liability For Youth Camps and Programs*In consideration for my child being allowed to participate in this GREENVILLE WET & WILD CAMP, I the undersigned, acknowledge, appreciate and agree that: 1. This CAMP/PROGRAM/PROJECT/CLUB affords my child the opportunity to participate in activities, including, but not limited to recreation, cooking, science experiments, hands on activities, interaction with animals and other people, etc. There are inherent choose to voluntarily allow my child to participate in this CAMP/PROGRAM/PROJECT/CLUB. I voluntarily assume full responsibility for any risk of loss, property damage or personal injury, including death, which may be sustained by my child as a result of his/her participation. 2. I certify that I have adequate resources necessary (e.g., health insurance, etc.) to provide for and pay for any medical costs that may directly or indirectly result from my child’s participation in this CAMP/PROGRAM/PROJECT/CLUB. I agree to pay for any medical costs that exceed the limits of my insurance coverage. 3. I understand that activities for this CAMP/PROGRAM/PROJECT/CLUB may be physically strenuous and I know of no medical reason why my child should not participate. 4. I hereby release, waive, and discharge Clemson University and its Board of Trustees, its officers, agents, employees and representatives from all claims, demands, liabilities, rights and causes of action of whatever kind or nature, that may result from or occur during my child’s participation in this CAMP/PROGRAM/PROJECT/CLUB, whether caused by negligence of the UNIVERSITY, its Board of Trustees, officers, agents, employees or representatives or otherwise. I also agree to indemnify and hold harmless the UNIVERSITY for any loss, liability, damage or costs, including court costs and attorney’s fees that may occur as a result of my or my child’s negligent or intentional act or omission while participating in this CAMP/PROGRAM/PROJECT/CLUB. I HAVE CAREFULLY READ THIS PERMISSION AND RELEASE OF LIABILITY AND HAVE HAD SUFFICIENT TIME TO SEEK EXPLANATION OF THE PROVISIONS CONTAINED ABOVE. AFTER CAREFUL CONSIDERATION, I SIGN THIS DOCUMENT VOLUNTARILY AND WITHOUT ANY INDUCEMENT. YES, I agree to the above conditions.NO, I do NOT agree to the above conditions.Discount Eligibility4H members, parents/guardians employed by Greenville County, and families with multiple campers may receive a $25 discount per child. Only one discount may be applied per child. Campers receiving scholarships are not eligible for these discounts.Discount EligibilityIf applicable, please select your discount. Discounted registrations must be paid in person or by mail to Greenville County Clemson Extension.4H memberGreenville County Employee2+ attending campersHow did you hear about Wet and Wild Camp?Returning camper4H or Soil and Water staff memberWord of mouthRadio or TVKidding Around Greenville