2023 HSWM Summer Camp Registration

1
Parent's Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Camper's Name* This field is required.
First Name
Last Name
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Grade Entering this Fall* This field is required.
8
Gender* This field is required.
Female
Male
Prefer Not to Answer
9
T-Shirt Size* This field is required.One t-shirt provided per camper. However, a t-shirt is not guaranteed if registered less than 10 days business days prior to camp start date.
Please Select
Please Select
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult XL
10
Have you been to camp at HSWM before?* This field is required.
Yes
No
11
Medical Considerations (Allergies, Physical, or Behavioral Limitations, etc.)
Huge
Large
Normal
Small
Ok
Ok
12
Emergency Contact Name* This field is required.Must be different than parent name at beginning of form, in case you are not available.
First Name
Last Name
13
Emergency Contact Phone Number
Area Code
Phone Number
14
Emergency Contact Relationship* This field is required.As a reminder, the emergency contact should not be the parent filling out the form.
15
Name(s) of those authorized to sign camper out of camp this summer:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
16
Insurance Provider* This field is required.
17
Insurance Policy Number* This field is required.
18
Child's Physician* This field is required.
19
Products & Payment* This field is required.
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My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
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ORDER SUMMARY
Total costUSD
Kids Day Out - Monday, June 5Ages 5-15
$50.00+Edit
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Kids Day Out - Tuesday, June 6Ages 5-15
$50.00+Edit
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Kids Day Out - Wednesday, June 7Ages 5-15
$50.00+Edit
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Kids Day Out - Thursday, June 8Ages 5-15
$50.00+Edit
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Back to Nature (June 12-15)Ages 8-12
$200.00+Edit
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Vet & Animal Careers (June 19-22)Ages 11-15
$200.00+Edit
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Media Mutts (June 26-29)Ages 8-12
$200.00+Edit
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Kids Day Out - Wednesday, July 5Ages 5-15
$50.00+Edit
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Kids Day Out - Thursday, July 6Ages 5-15
$50.00+Edit
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Kids Day Out - Friday, July 7Ages 5-15
$50.00+Edit
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HSWM 101 (July 10-13)Ages 5-11
$200.00+Edit
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Animal Planet (July 17-20)Ages 5-11
$200.00+Edit
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'FUN'draising Camp (July 24-27)Ages 8-12
$200.00+Edit
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My First Pet (July 31-August 3)Ages 8-12
$200.00+Edit
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HSWM 102 (August 7-10)Ages 9-13
$200.00+Edit
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Back to Nature (August 14-17)Ages 8-12
$200.00+Edit
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Enter Coupon
Total cost $0.00
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
20
Disclaimer* This field is required.Please sign below to accept the terms and conditions. In consideration for my (our) child above being permitted to participate in Humane Education Camp activities provided by Humane Society of West Michigan, its employees, agents, volunteers, and/or affiliates (collectively referred toas “HSWM”), I (we), agree to the following: I understand that my child will be interacting with unfamiliar animals throughout the term of the summer camps. I certify that there are no physical, emotional, or mental problems or limitations associated with my child’s participation in these or any other camp activities. While the Summer Camp animals have been temperament tested by HSWM and HSWM in good faith believes the animals will be safe for interaction with the public, animals by their nature are unpredictable and there are many factors that can affect their behavior. HSWM will have complete discretion in determining how to react in all circumstances including unpredictable animal behavior. I understand that there are unpredictable risks and dangers inherent to interacting with any animal. For myself and my child, I acknowledge and assume the risks involved in these inherently dangerous activities, and for any damage; illness; injury; including, without limitation, animal bites, lacerations, or scratches; or death resulting from such activities. I certify that I have the authority to enter into this agreement on behalf of my child and release and waive any claims that I or my child may have against HSWM with respect to any loss; injury, including, without limitation, animal bites, lacerations, or scratches; illness; damage; or death occurring to my child while he/she is in the custody and care of HSWM as well as any related claims that I may have. I agree to indemnify and hold harmless HSWM from and against any and all liability and costs (including attorney fees) related to any such claim asserted against HSWM by or on behalf of my child or me. I agree that this release, waiver of liability and indemnification agreement is intended to be as broad and inclusive as permitted by the laws of the of Michigan, and that if any portion there of is held invalid, it is agreed that the balance shall not with standing continue in full legal force and effect. In the event of an accident or injury to my child, I authorize HSWM to make whatever transportation, diagnosis, and/or treatment arrangements as they, in their sole discretion, deem to be appropriate in the circumstances. I agree that my insurance or I personally will be liable for any costs incurred for the transportation, diagnosis, and/or treatment of my child. Transportation, diagnosis, and/or treatment of my child should proceed whether or not I can be contacted. Below I am providing my contact phone number(s) and HSWM is not responsible to identify any other means to contact me if that is unsuccessful. I grant HSWM the right to use my name, portrait, photograph, video segment, likeness, or other image, and those of any minor named below, on whose behalf I am signing, for marketing, public relations, and/or educational purposes. I grant HSWM the right to use the name or image described above in print, video and/or electronic media. I understand that HSWM retains all rights to use, publish or distribute the portraits, photographs, video segments, likenesses, or other images and has the right to do so without seeking any further permission from me or providing me any royalty. I understand that notification is not a condition to HSWM’s use or publication of my name or image for marketing, public relations and/or educational purposes. I understand that full refunds may only be provided with two week’s full notice of cancellation, prior to your scheduled attendance, minus a $20 processing fee. I understand that refunds will not be provided without notice of cancellation and that refunds cannot be provided during the scheduled week of camp. Please Note: Animal time during camp may be limited or varied depending on the day, the camp, and what animals we have at the time. Shelter animals are in an extremely stressful environment, and our goal is to provide the campers and animals with a safe and enriching experience. We appreciate your patience and understanding as we all strive to provide shelter animals and campers a safe environment. I HAVE READ AND UNDERSTAND THE ABOVE AND AGREE TO BE BOUND BY THE TERMS OF THIS DOCUMENT.
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We love animals, but please verify that you are human!* This field is required.Please check you email for confirmation after submitting this form. If you do not see your confirmation please check your spam folder.
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