Country Camp Registration Form

Summer 2026 Registration
You must send a non-refundable $25 deposit per week (per child) to hold your child’s spot. Deposits can be made via Venmo @countrycamp or check. Checks should be payable to Country Camp, LLC and mailed to 3418 Osage Street SW Iowa City, IA 52240. Deposits are credited toward the cost of the session. We will confirm registration via email after we have received your deposit.
Camper Information
Camper's Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Grade in Fall 2026*
We are now accepting wait list only.

Please see below.
You do not need to pay a deposit to be placed on the wait list. We will contact you via email if a spot opens up from the wait list.
Please put my camper on the WAIT LIST for (select all weeks that you are interested in)

June 8 - June 12 (Session #1 Siege of Trollfjord)June 15 - June 19 (Session #1 Siege of Trollfjord)June 22 - June 26 (Session #2 Return of the Morgan Diamond)June 29 - July 3 (Session #2 Return of the Morgan Diamond)July 6 - July 10 (Session #3 Shakespeare's Troupe)July 20 - July 24 (Session #4 Sound Incorporated)July 27 - July 31 (Session #4 Sound Incorporated)August 3 - August 7 (Session #5 Roscommon)August 10 - August 14 (Session #5 Roscommon)August 17 - August 21 (Session #6 Boarwald Academy)
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Emergency Information
First Emergency Contact's Name *

First NameLast Name
Relationship*
Phone Number*
Second Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Are there any specific concerns for your child? If yes, please explain.
Does your child have any allergies? If yes, please list. (You will send your child with a lunch and a snack each day. Please note that we are not a nut-free camp.)
Is there anything else you would like to share with us?
Informed Consent, Medical Release and Authorization

All of the information provided above is true and correct to the best of my knowledge.

I understand that Country Camp, LLC assumes no responsibility or liability for injuries/illnesses of my child. I further understand that I hold Country Camp, LLC, its officers, agents, employees, and volunteers harmless from any and all liability or claims which may arise out of my child’s participation in Country Camp, LLC programs.

I grant permission to Country Camp, LLC to provide care for my child. I grant permission for my child to use all of the play equipment and participate in all of the activities of Country Camp, LLC. This contract is effective for the duration of my child’s enrollment in Country Camp, LLC.

As the parent or legal guardian, I hereby give consent to Country Camp, LLC that my child may be given emergency treatment to include 1st Aid/CPR by a qualified staff member of Country Camp, LLC. I also give permission for my child to be transported by an aid car, ambulance, or staff car to the nearest medical treatment center or hospital if necessary.

As the parent or legal guardian, 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 camper. 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.

In the event that it becomes necessary for Country Camp, LLC staff to obtain emergency care for my child, neither the staff nor Country Camp, LLC assumes financial liability for expenses incurred because of accident, injury, illness, and/or unforeseen circumstances.
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*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
I have paid my deposit via

Venmo (please include your child's name in the notes)Check (please include your child's name on the memo line)
Should be Empty:

Summer 2026 Registration