WESTERN SPRINGS JULY 2025 Registration Form

WESTERN SPRINGS JULY 2025 Registration Form
Camper 1 Information:
Name*

First NameLast Name
Birthdate*

MonthDayYear
Age*
Parent Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Parent Name

First NameLast Name
Primary Parent Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
School*
Grade (Currently)*
T-Shirt Size*
Family Background
Primary Daytime Caregiver:
Health History
Allergies
If applicable, please describe the typical allergic reaction of your child.
Medications. (If medicine is to be administered at camp please call the Camp Office 815-354-0662 for a Physician’s Medical Release Form that must be completed by your child’s doctor.)
Food Restrictions
Health Insurance Information
Carrier or Plan Name
Group #
Please provide any additional information you feel would be helpful.
Parent/Guardian Signature | Date

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Camper 2 Information
Camper 2 Information:
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
School
Grade (Currently)
T-Shirt Size
Family Background
Primary Daytime Caregiver
Health History
Allergies
If applicable, please describe the typical allergic reaction of your child:
Medications (If medicine is to be administered at camp please call the Camp Office 815-354-0662 for a Physician’s Medical Release Form that must be completed by your child’s doctor.)
Food Restrictions
Health Insurance Information
Carrier or Plan Name
Group #
PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL WOULD BE HELPFUL:
Parent/Guardian Signature | Date

Clear

Camper 3 Information:
Camper 3 Information
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
School
Grade (Currently)
T-Shirt Size
Family Background
Primary Daytime Caregiver
Health History
Allergies
If applicable, please describe the typical allergic reaction of your child:
Medications. (If medicine is to be administered at camp please call the Camp Office 815-354-0662 for a Physician’s Medical Release Form that must be completed by your child’s doctor.)
Food Restrictions
Health Insurance Information
Group or Carrier Name
Group #
PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL WOULD BE HELPFUL:
Parent/Guardian Signature | Date

Clear

Camper 4 Information
Camper 4 Information
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
School
Grade (Currently)
T-Shirt Size
Family Background
Primary Daytime Caregiver
Health History
Allergies
If applicable, please describe the typical allergic reaction of your child:
Medications (If medicine is to be administered at camp please call the Camp Office 815-354-0662 for a Physician’s Medical Release Form that must be completed by your child’s doctor.)
Food Restrictions
Health Insurance Information
Carrier or Carrier Name
Group #
PLEASE PROVIDE ANY ADDITIONAL INFORMATION YOU FEEL WOULD BE HELPFUL:
Parent/Guardian Signature | Date

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Parent Information:
Parent's Primary E-mail*
Parent 1 Name*

First NameLast Name
Parent 1 Contact Phone*

Area CodePhone Number
Parent 2 Name

First NameLast Name
Parent 2 Contact Phone

Area CodePhone Number

Emergency Information:
Contact Person in case of Emergency if parents are unavailable:*

First NameLast Name
Relationship to camper:*
Emergency Contact Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Phone Number*

Area CodePhone Number

Parent or Guardian Consent:
1. I request that my child be admitted to Summer City Adventures. I understand that as the parent/guardian submitting this registration form on behalf of the above named child, that I, alone, am responsible for payment of the program fees in accordance with the following schedule: 50% of balance due by March 1, 2025; final balance due in full by May 1, 2025. After May 1, 2025, all program fees are due in full at time of registration. Payments can be made with a personal check made out to Summer City Adventures, Venmo (@summercityadventures), or Chase Quickpay (josh@summercityadventures.com).
2. I understand that ALL FORMS must be filled out, signed and returned with the Registration Form.
3. I give permission for my child to participate in any and all camp activities, except those specifically prohibited, in advance, and given to the Camp President in writing.
4. I give permission for my child to go on trips outside the camp facility via the form of public transportation or motor vehicle.
5. I give my permission for my child to be included in program photos, videos, or multimedia presentations.
6. I understand that Summer City Adventures is not responsible for the personal property of my child, or damage/loss of my child’s personal property while participating at Summer City Adventures.
7. I hereby release and hold harmless Summer City Adventures, its officers, employees, agents, representatives, volunteers, heirs, executors, and assigns from all liability for personal injury, including death arising out of my child’s participation in this camp program. I understand that this release and indemnification releases liability for the conduct of Summer City Adventures and its officers, employees, agents, representatives, volunteers, heirs, executors and assigns.
8. In the event I cannot be reached in an emergency involving my child, I hereby give permission to the appropriate medical personnel, selected by Summer City Adventures to provide medical treatment deemed necessary by such medical personnel, including, but not limited to X-rays, tests, injections, blood transfusions, hospitalization, anesthesia and surgery.
9. I give permission for my child's phone number and parent email address to be shared with other families on a written list.
10. Refund Policy—If a cancellation occurs prior to April 1, 2025, the deposit less the $100 application fee is refundable. Deposits are non-refundable and non-transferable after May 1, 2025. There will be no refunds after May 1, 2025.
11. Health and Wellness Policies for Attending Camp
  The state of Illinois is currently in Phase 4 of the Restore Illinois Plan.
  The following guidelines will be in place all camp in order to ensure the health and safety of our families.
  Everyone that enters the building must wear a mask and sanitize their hands, including staff, teachers, students and parents. Everyone must bring their own masks.
  Our waiting areas will be unavailable for use. We ask that parents drop off and pick up their child at the front entrance. Young children may be accompanied into the building.
  Some counselors may choose to meet their students at the entrance to take their temperatures. Campers with visible cold symptoms (cough, runny nose, upset stomach) will be sent home.
  Counselor/staff temperatures will be taken upon arrival and they will be sent home if not within a healthy range.
  If the camper or family member is sick, experiencing COVID-19 symptoms, has been exposed to someone with COVID-19, or is immunocompromised, please stay home.
  Campers will keep six (6) feet of distance from teachers, staff and other campers as much as possible. Counselors will adhere to this in small groups as well.
  We have purchased specialized sanitizing products and will continue to clean during in addition to our weekly professional cleaning service.
  If a student is experiencing COVID-19 symptoms, or has been exposed to someone with COVID-19, we ask that they inform our office immediately and stay home. For anyone interested in COVID-19 testing, this website is updated regularly:
  https://dph.illinois.gov/covid19/covid-19-testing-sites
  Protocol in the case that a counselor, staff member or camper is diagnosed with COVID-19 and has symptoms:
  Summer City Adventures will close down camp until we are able to conduct professional deep clean and sanitization (minimum of 2 days). Summer City Adventures will initiate contact tracing with involved parties, to the best of our ability. The infected person may return to Summer City Adventures once they have tested negative for COVID-19. All other people who were in contact with the infected person must quarantine from Summer City Adventures for 10 days before returning to camp.
  
  COVID-19 Warning:
  
  Summer City Adventures has taken enhanced health and safety measures for you, our families, our campers, and our staff. You must follow all posted instructions while visiting our camp! An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers for Disease Control and Prevention, senior citizens and people with underlying medical conditions are especially vulnerable. By visiting our camp, you voluntarily assume all risks related to exposure to COVID-19. Help keep each other healthy.
Please sign below to agree to the above terms.

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Please select a payment method: $600 (Three Week) OR $400 (Two Week) Deposit due immediately*

Zelle (josh@summercityadventures.com or 815-354-0662)Venmo (@summercityadventures)
How many campers?*

1234
How many weeks? (July 14th through August 1st) (THREE WEEK) OR (July 14th through 25th) (TWO WEEK)*

2 Weeks (WAITLIST) (July 14th through 25th) ($1,325) ($400 Deposit)3 Weeks (July 14th through August 1st) ($1,800) ($600 Deposit)
Should be Empty: