Eco-Adventures with Pollinator Pals 2025 Camp Registration Form

Eco-Adventures with Pollinator Pals

July 28-30 | Ages 7-12 | 10am-1pm each day | $99 per camper
Eco-Adventures with Pollinator Pals

July 28-30

Join us for an exploration of the tiny creatures that help our food systems and ecosystems function: POLLINATORS! Marvel at the local biodiversity of the Jacksonville area as we walk to nearby Beekman Arboretum, and make awesome crafts at the JCC! This three-day camp will lead you on a micro-to-macro-scopic journey through the ecosystem from a pollinators point of view, led by Pollinator Project Rogue Valley.

10:00am - campers arrive at the Jacksonville Community Center
10:00am-1:00pm - explore nearby ecosystems and local pollinators, lunch, craft
1:00pm - parent/guardian pick-up at the Jacksonville Community Center

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

First NameLast Name
Date of Birth*

MonthDayYear
Date
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.

Camper #2 (Optional)
2nd Child's/Camper's Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
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.

Camper #3 (Optional)
3rd Child's/Camper's Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
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.

Parent/Guardian Information

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

First NameLast Name
Parent/Guardian Email:*
example@example.com
Parent/Guardian 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:*

Additional adult authorized to pick up my child/children (Optional):
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.

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 (Optional)
Emergency Contact #2:

First NameLast Name
Phone Number to be used in an emergency:
Please enter a valid phone number.

Waivers for the Jacksonville Community Center, Pollinator Project Rogue Valley, City of Jacksonville Parks, 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 program 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. 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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RELEASE AND WAIVER FOR POLLINATOR PROJECT ROGUE VALLEY: By signing below, the Parent/Guardian hereby 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 by signing, agrees to assume all responsibility for any harm in relation to those risks and to forever discharge, release, defend, indemnify and hold harmless Pollinator Project Rogue Valley, and each of its directors, officers, employees, agents and their heirs, successors and assigns 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 Pollinator Project Rogue Valley in the event of an emergency to provide first aid or other treatment. The Parent or Guardian understands that Pollinator Rogue Valley assumes no 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. Additionally, by signing below you agree to grant and convey to the Pollinator Project Rogue Valley 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: The Parent/Guardian herby releases the City of Jacksonville and agrees to hold harmless the City of Jacksonville 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. The Parent/guardian understands that this Release discharges the City of Jacksonville from any liability or claim that the parent may have against the City of Jacksonville with respect to physical injuries, illness, death or property damage resulting from their children's activities in the City of Jacksonville. The Parent or Guardian further understands that the City of Jacksonville 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 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

My Products*

Eco-Adventures with Pollinator Pals July 28-30, 2025 Product Image

Eco-Adventures with Pollinator Pals July 28-30, 2025A 3-day camp for 7-12 year olds in Jacksonville Oregon.

$99.00 Quantity

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Eco-Adventures with Pollinator Pals

Camper #1

Parent/Guardian Information

Emergency Contact #1

Waivers for the Jacksonville Community Center, Pollinator Project Rogue Valley, City of Jacksonville Parks, and Medical Release (Required)

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