2025 Peaks & Bounds Summer Camp Registration Form

SOLD OUT Sprouts Adventure Camp 1 (June 9-11) @ Seedlings KindertribeSprouts Adventure Camp 2 - (July 30-Aug 1) @ Seedlings KindertribeSOLD OUT - Barnyard Wonder Camp (June 16 & 17) @ Laughing Buck FarmForest Grove Discovery - EXPLORERS (June 24-27) @ OwlTree FarmForest Grove Discovery - ADVENTURERS (July 15-18) @ OwlTree FarmBloom & Grow Camp (July 7, 14, 21, 28) @ Dandelion FarmsWestlands Park Play Group (Ages 4-6)Westlands Park Social Group (Ages 7-9)

Camper Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade for 2024-2025 school year

Age*

Gender *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name (primary contact) *

First NameLast Name

Cell Number*

Format: (000) 000-0000.

E-mail*

example@example.com

E-mail for secondary contact (optional)

example@example.com

Emergency Information

Emergency Contact's Name (in the event primary contact cannot be reached)*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Please describe any allergies (seasonal, food, insect) and treatment protocol *

Please list dietary restrictions (Guardians are asked to supply lunch/snacks however group snacks are available as needed)*

Does you child complete toileting independently? If not - please describe level of support/assistance (diaper changes, transfer support, wiping etc.)*

Please provide background on your camper including: any relevant medical history, diagnosis (es), sensory needs, communication style (AAC, sign language, gestalt language processor, etc.), physical abilities, assistive devices, or any supports needed to enhance your camper's participation.*

Please describe the campers's interests, strengths, what they are hoping to do at camp (e.g., feeding animals, group games, messy play, themed play, specific games/activities) or anything else you would like us to know about your camper *

Please list any general goals you have for your camper while at camp *

Privacy Statement: "I understand that Peaks and Bounds will maintain my privacy to the highest standards. I understand that personal information will not be shared with anyone not affiliated with Peak and Bounds I understand that personal information received through this registration will only be shared with professional staff and volunteer staff at Peaks and Bounds to ensure the safety of my child and to ensure my child receives appropriate support needed while at camp."*

Yes

YesNo

Consent & Release

Peaks & Bounds Inc. is committed to conducting its services and activities in the safest manner possible and holds the safety of participants in the highest possible regard. Participants and parents registering their children in services and activities must recognize, however, that there is an inherent risk of injury when choosing to participate. Peaks & Bounds Inc. strives to reduce such risks and insists that all participants follow safety rules and instructions which have been designed to protect the participant’s safety.

I acknowledge that I have been informed of the nature of the camp activities, and I give my permission for my child to participate fully in all camp activities. I recognize and acknowledge that there are certain risks of physical injury to participants in the Peaks & Bounds Inc. camp(s) and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such service(s).

Medical Emergency: In the event of an emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give my permission for the camp staff to seek and authorize any emergency medical treatment for my child that may be necessary during the camp session. I understand that the camp will not be held responsible for any such medical expenses incurred.

I, the undersigned, agree to release, indemnify, and hold harmless the camp, its staff, volunteers, and affiliated organizations from any and all claims, liabilities, damages, or expenses arising out of or in connection with my child's participation in the camp, including but not limited to any injury, illness, or accident that may occur during the camp session.

Yes

Photo Release

Option 1 - Personal, Community, & Promotional Use: I grant permission for Peaks & Bounds to capture photographs, videos, and other media of my child during program activities. These materials may be shared with other camp families and myself for personal and community engagement purposes. I authorize the use and reproduction by Peaks & Bounds Inc. of any and all photographs and any other audiovisual materials taken of the child, child’s family, or guests while at camps for use in promotional materials, social media photo/video postings, educational activities, exhibitions, or for any other use for the benefit of Peaks & Bounds Inc.

Option 2 - Personal & Community Use: I grant permission for Peaks & Bounds to capture photographs, videos, and other media of my child during program activities. These materials may be shared with camp families and myself for personal and community engagement purposes. However, I do not consent to the use of these materials in any public-facing promotional materials, including but not limited to the Peaks & Bounds website, social media, brochures, or advertisements.

Option 3 - Personal Use ONLY: I grant permission for Peaks & Bounds to capture photographs, videos, and other media of my child during program activities, to be shared exclusively with me.

Option 4 - I DO NOT grant permission for Peaks & Bounds to capture photographs, videos, and other media of my child during program activities.

Option 1 - I consent to person, community, and promotional useOption 2 - I consent to personal & community useOption 3 - I consent to personal use onlyOption 4 - I do not consent to any photos being taken of my child

Cancellation Policy

1. Cancellation 60 days or more before camp start date will result in a full refund.

2. Cancellation of a camp 30-60 prior to the camp start date will result in forfeit of half of the registration fee with refund of the other half.

3. Cancellation by the family less than 30 days before camp start time will result in forfeit of the entire registration fee.

4. Cancellation by the family part way through a camp due to illness or vacation or other unexpected events, cannot be refunded and families forfeit the registration fee.

5. Cancellation of a camp by Peaks & Bounds, Inc because of low numbers, would result in full refund.

Yes

Laughing Buck Farm Waiver

If your camper is attending Barnyard Wonder Camp at Laughing Buck Farm please complete the waiver located here: Laughing Buck Farm Waiver

My camper is attending a Barnyard Wonder Camp and I have completed the waiver for Laughing Buck FarmMy camper is not attending camp at Laughing Buck Farm

Payment Information

Please select your camp option(s) and complete payment before submitting registration*

Sprouts Adventure Camp (June 9-11)

Sprouts Adventure Camp (July 30- August 1st)

Barnyard Wonder Camp

Forest Grove Discovery Camp Explorers

Forest Grove Discovery Camp ADVENTURERS

Bloom & Grow Garden Camp

Westlands Park Play Group Ages 4-6

Westlands Park Social Group Ages 7-9

*For use of CES - please use discount code CESWAIVER to reserve your spot and please immediately connect your child's case manager to us via email (Emily@peaksandbounds.com).

*For sliding scale, please use discount code SLIDINGSCALE to reserve your spot and reach out to us immediately via email (Emily@peaksandbounds.com) re: sliding scale options.

Self-pay full priceSelf-pay sliding scaleCES waiver

Confirmation

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.

Date*

Date

Signature*

Peaks & Bounds Summer Camp Registration

Camper Information