Jacksonville Woodlands Exploration Camp July 2023 Registration Form

Jacksonville Woodlands Exploration Camp

July 17th-20th Ages 6-10 Camp will operate from 9am-12pm each day.
Kids will have a blast in this 4-day camp, exploring our local woodlands with experienced instructor, Tara Laidlaw, from the Southern Oregon Land Conservancy. Campers will meet at the JCC and then walk into the Jacksonville Woodlands for exploration, nature journaling, games and activities. This camp will help local kids learn about and connect with nature, make friends, and have fun outside!

8:45-9:00 campers arrive at the Jacksonville Community Center
9:00-12:00 guided hike, activities, and lunch in the Jacksonville Woodlands
12:00-12:15 parent pick-up at the Jacksonville Community Center
Volunteers Needed!

The JCC is proud to operate with dependence on community volunteers, and summer camps are no exception. We are looking for a couple of parents each day to help out with this camp. We will offer a discount on the cost of the camp if you are able to volunteer.

Typically if a parent is willing to volunteer for 2 days (approx 6-7 hours) the camp is offered at a 50% discount to one of their children. If volunteering all 4 days is preferable, the camp is offered without cost to one child.

We have approximately 2-4 volunteer positions available for each week of these camps. A brief online application and background check is the only needed paperwork. We will have a brief orientation and send an instructional manual for any questions you may have.

If you are interested in volunteering, please exit this form and email sarahg@jacksonvillecommunitycenter.org. She will reserve a spot for your child/ren and send you a volunteer form. Once completed you will be issued a coupon code to be used at checkout.

Thank you for your support of the Jacksonville Community Center!

Parent/Guardian #1 Information

Please list the primary person who will be dropping off and picking up your child (additional people may be listed below)
Parent/Guardian #1:*

First NameLast Name
Parent/Guardian #1 Email:*
example@example.com
Parent/Guardian #1 Cell Phone Number*
Please enter a valid phone number.
Parent/Guardian/Child Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This person is authorized to pick up the child/children registered on this form:*
- Parent/Guardian #2 Name
  
  First NameLast Name
- Parent/Guardian #2 Email
  example@example.com
- Parent/Guardian #2 Cell Phone Number
  Please enter a valid phone number.
- This person is authorized to pick up the child/children registered on this form:
- Additional Adult authorized to pick up my child/children:
  
  First NameLast Name
- Additional Adult Email:
  example@example.com
- Additional Adult Cell Phone Number:
  Please enter a valid phone number.
- This person is authorized to pick up the child/children registered on this form.

Emergency Contact #1

Please list the first person you would like us to contact in an emergency
Please list at least one Emergency Contact's Name and Number for all children registered on this form- Emergency Contact 1:*

First NameLast Name
Phone number to be used in an emergency:*
Please enter a valid phone number.
- Emergency Contact #2:
  
  First NameLast Name
- Phone Number to be used in an emergency:
  Please enter a valid phone number.

Camper #1
1st Child's/Camper's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I will need JCC staff member to administer medication to 1st Child (an additional permission form will be sent after this form is submitted)*
This child has an allergy, health condition, is taking medication, or has a behavior issue that the volunteers should be aware of:*
Please list those allergies, health conditions, medications or behaviors that volunteers should be aware of:
Ex. He/she has a peanut allergy, has an epi pen, pacemaker, etc.
- 2nd Child's/Camper's Name
  
  First NameLast Name
- Date of Birth:
  
  MonthDayYear
  Date
- I will need JCC staff member to administer medication to 2nd Child (an additional permission form will be sent after this form is submitted)
- This child has an allergy, health condition, is taking medication, or has a behavior that the volunteers should be aware of:
- Please list any allergies, health conditions, medications or behaviors that the volunteers should be aware of:
  Ex. He/she has a peanut allergy, has an epi pen, pacemaker, etc.
- 3rd Child's/Camper's Name
  
  First NameLast Name
- Date of Birth:
  
  MonthDayYear
  Date
- I will need JCC staff member to administer medication to 3rd Child (an additional permission form will be sent after this form is submitted):
- This child has an allergy, health condition, is taking medication, or has a behavior that the volunteers should be aware of:
- Please list any allergies, health conditions, medications or behaviors that the volunteers should be aware of:
  Ex. He/she has a peanut allergy, has an epi pen, pacemaker, etc.

Waivers for the Jacksonville Community Center, Southern Oregon Land Conservancy, Jacksonville Parks and Woodlands and Medical Release (Required)

Signing all waivers with a somewhat legible signature is required.
By signing the waivers below, I understand that he following waivers pertain to ALL of the children I have previously listed on this form.
JACKSONVILLE COMMUNITY CENTER LIABILITY WAIVER: I hereby agree to the following: In consideration of being permitted by the Jacksonville Community Center to participate in activities sponsored by the Jacksonville Community Center, I hereby waive, release and discharge any and all claims for damage for personal injury, death or property damage which I may have, or which may hereafter accrue to me, as a result of participation in activities at said facilities. This release is intended to discharge in advance the Jacksonville Community Center, its officers, employees, agents, independent contractors and volunteers from any and all liability arising out of or connected in any way with my participation in activities at this or any other facility or outdoor space even though that liability may arise out of negligence or carelessness on the part of those parties. It is understood that activities such as the ones I will be participating in may involve an element of risk and danger of accidents and knowing those risks, I hereby assume those risks. It is further agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns. I agree to indemnify and to hold harmless, the Jacksonville Community Center, its officers, employees, agents, independent contractors and volunteers from any loss, liability, damage, cost or expense which they may incur as the result of my death or any injury or property damage that I may sustain while participating in any activity at this or any other facility or outdoor space. I recognize that this class may require physical exertion that may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in this class. By participating in JCC activities, I consent to have my image, in any form, including but not limited to photographs and video, used by JCC in connection with its website, social media, and/or printed materials. If my child is participating in a JCC activity or class, I consent that my child’s photo and/or video may be used by JCC in its nonprofit use on its website, social media or in printed materials. I consent to receive emails from Jacksonville Community Center about news and information. Unsubscribe links are provided at the bottom of every email. If the participant is a minor: Consent of Parent/Guardian: I am the parent or legal guardian of the participant(s) listed above. I hereby consent that the participant(s) may participate in activities at this, or any other facility or outdoor space and I hereby execute this Waiver on his/her behalf. I hereby affirmatively state that the said Participant(s) is physically able to participate in said activity. I hereby agree to indemnify and hold the persons and entities mentioned above free and harmless from any loss, liability, damage, cost or expense that they may incur as a result of the death or any injury or property damage that said participant may sustain while participating in activities at the Jacksonville Community Center, another outdoor space, or other facility. Furthermore, I understand the inherent risk of exposure to the minor(s) I am responsible for and others to COVID-19 in any public space where people are present. By attending this camp, I expressly agree that the minor(s) will comply with all rules and safety guidelines put in place by the JCC or published by the CDC or state or local health departments, and voluntarily assume all risks related to exposure to COVID-19. I HAVE CAREFULLY READ THIS WAIVER AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE JACKSONVILLE COMMUNITY CENTER AND I SIGN IT OF MY OWN FREE WILL.BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE*

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SOUTHERN OREGON LAND CONSERVANCY: Parent/guardian waiver for minors: A parent/ guardian or individual with legal authority to act on their behalf must sign this release on behalf of each participating minor (under the age of 18 years of age).I verify that I am the parent/guardian and/or have the legal authority to enter into this agreement on behalf of the minor(s) listed above. By signing below, I acknowledge that there are inherent risks associated with this activity, including, but not limited to, those posed by natural and other hazards in addition to the health risks associated with outdoor and strenuous physical activity and agree to assume all responsibility for any harm in relation to those risks and to forever discharge, release, defend, indemnify and hold harmless the Southern Oregon Land Conservancy, and each of its directors, officers, employees, agents and their heirs, successors and assigns, “released parties”, from any and all liability, claims, and demands of whatever kind or nature, in law or in equity, which arise from, or are related to, the activity noted above including, but not limited to, those relating to any form of injury, illness, death or property damage that may result, now or in the future, from the activity or for any actions taken by the Southern Oregon Land Conservancy in the event of an emergency to provide first aid or other treatment. Additionally, I accept full responsibility for all medical expenses incurred as a result of the minor(s)’ participation in the activity or entry on the premises, and I agree to forever discharge, release, defend, indemnify and hold harmless the released parties from any claim brought by, or on behalf of the minor(s). I further agree to save, defend, hold harmless and indemnify to forever discharge, release, defend, indemnify and hold harmless released parties from all liability, loss, claim, damage, or costs whatsoever which may arise because of any lack of authority or capacity for me to act or bind the minor(s) to this agreement or otherwise release the released parties on behalf of the minor(s) and their parent or legal guardian. Furthermore, I understand the inherent risk of exposure to the minor(s) I am responsible for and others toCOVID-19 in any public space where people are present. By attending this camp, I expressly agree that the minor(s) will comply with all rules and safety guidelines put in place by SOLC or published by the CDC or state or local health departments, and voluntarily assume all risks related to exposure to COVID-19. Additionally, I hereby agree to grant and convey to the Southern Oregon Land Conservancy all right, title and interest in any and all photographs, images, video or audio recordings of them or their likeness made in connection with the activity described above. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE*

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RELEASE AND WAIVER FOR JACKSONVILLE CITY PARKS AND WOODLANDS: The Parent/Guardian herby releases the City of Jacksonville and Woodlands Association and agrees to hold harmless the City of Jacksonville and Woodlands Association from any and all liability, claims, and demands of whatever nature, which arise from their children's activities at parks or public spaces in the City of Jacksonville and Jacksonville Woodlands. The Parent/guardian understands that this Release discharges the City of Jacksonville and Woodlands Association from any liability or claim that the parent may have against the City of Jacksonville and Woodlands Association with respect to physical injuries, illness, death or property damage resulting from their children's activities in the City of Jacksonville and Jacksonville Woodlands. The Parent or Guardian further understands that the City of Jacksonville and Woodlands Association does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability insurance in the event of injury or illness sustained. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE*

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MEDICAL RELEASE AND AUTHORIZATION: As Parent and/or Guardian of the above named participant(s), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant(s) above. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Jacksonville Community Center and its affiliates including Staff, Directors, Volunteers, Independent Contractors and Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered activity. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. Parent or Guardian further understands that the Jacksonville Community Center does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health, or disability compensation in the event of injury or illness sustained. BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE*

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If you have trouble making a payment on this form, please call: the JCC at 541-702-2585

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Jacksonville Woodlands Exploration Camp - July 17th-20th , 2023

A camp for 6-10 year olds in Jacksonville Oregon.

$150.00 Quantity

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Jacksonville Woodlands Exploration Camp

Parent/Guardian #1 Information

Emergency Contact #1

Camper #1

Waivers for the Jacksonville Community Center, Southern Oregon Land Conservancy, Jacksonville Parks and Woodlands and Medical Release (Required)

If you have trouble making a payment on this form, please call: the JCC at 541-702-2585