2026 Kids Camp Online Registration

Camper Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Camper Age (As of June 2026)*
****If your Child is over the age of 13 Please contact Raven McIntosh or Kelly Pratt to apply for a Jr Counselor position on our Kids Camp Staff. 316-322-4262****
Full Home Address*
Date of Birth*

MonthDayYear
Date
Gender*
Hospital preference*
Emergency Contact #1*

First NameLast Name
Phone Number (Cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to camper*
Emergency Contact #2 *

First NameLast Name
Phone Number (Cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Home)
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Camper*
If your child needs transportation to and from camp, please indicate below.*

Andover (911 N Andover Rd)I will provide transpotation for my child
Any camper that needs transportation, please note the following schedule

TO camp: 7:20 a.m. Bus Leaves Andover EMS/FIRE Department 911 N. Andover Road

Returning FROM camp: 6:00 p.m. Bus arrives at Andover EMS/FIRE Department
Photography/videography release As a parent or guardian of this camper, I hereby consent to the use of photographs/videotape taken during this camp for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet or other media sources I do this with full knowledge and consent and waive all claims for compensation for use, or for damages. I give consent to photograph my child.*

YesNo
Parent Signature*
Date

MonthDayYear
Date
Medical History Form

Butler County EMS Kids Camp
Camper Name*

First NameLast Name
Age*
Medical History or Special Concerns*
Allergies (food, medications or environmental)*
Medication- (Any medication to be given to the camper during camp must be brought in the original labeled bottles. All inhalers must be clearly marked with the camper's name): List medications below*
If applicable please list insurance information below:
Insurance Provider Name*
IE Aetna, Blue Cross Blue Shield, ECT.
Insurance Identification Number*
I First Name* Last Name* give my permission for my child First Name* Last Name* to receive over-the-counter medications (i.e. headache or allergy) if necessary.
*

YesNo
Signature*
Date

MonthDayYear
Date
Release and Consent Form for Medical Care:

I understand that one of the purposes of the Butler County EMS Kids Camp is to teach the safe use of life-saving techniques and equipment. Camp instructors and counselors will closely supervise actual demonstrations of the equipment involving campers. However, I acknowledge that there is the possibility of accidents. I release all instructors, counselors, sponsors, Butler County and Butler County EMS from liability, and agree to hold them harmless from all claims in the event of injury to my child, so long as due care has been exercised by these parties.

Medical care for minor injuries will be available at the camp and transportation to area hospitals will be available if necessary. I understand that if a serious illness or injury occurs, I will be notified. While efforts to reach me are continued, I hereby give permission for emergency treatment or surgery as recommended by the attending physician.
Preferred Hospital Destination*
Secondary Hospital Destination*
I have read and understand the above information.
Signature*
Date*

MonthDayYear
Date
Firearm Safety Demonstration Waiver

Butler County EMS Kids Camp
This year at Kids Camp we will have the Butler County Sheriff's Office holding a Firearm safety demonstration. Below we have provided the details of the demonstration provided by the Sheriff's Office.

"During this class, the kids will learn the basics of Firearm Safety. They will learn how to properly handle and carry a firearm and learn how to insure the firearm is safe. They will learn the different actions of firearms and where the safety is located. Kids will not be handling real Firearms during this class."

If you have further questions or concerns regarding this demonstration, please contact Sgt. Repstine at rrepstine@bucoks.com.

Please indicate your desired response, then sign and date the waiver.
If this form is not completed, your child will be automatically opted out of the demonstration*

Yes, I would like my child to attend this demonstrationNo, I would not like my child to attend this demonstration
Parent/Guardian Name*

First NameLast Name
Signature*
Date

MonthDayYear
Date
Camper's Name *

First NameLast Name
Age*
Gender*

MaleFemale
Student's School*
Camper's T-shirt (included with paid registration)*

Children's SmallChildren's MediumChildren's LargeChildren's X-largeAdult SmallAdult MediumAdult LargeAdult X-Large
Additional shirts are available for purchase at $20.00 each. If you would like an additional shirt please indicate size and quantity in the box below. Payments are due with registration payment

PARENT OR GUARDIAN AGREEMENT AND CONSENT TO WAIVER AND RELEASE OF LIABILITY AND INDEMNITY AGREEMENT FOR THE BUTLER COUNTY EMS (BCEMS) KID'S CAMP PROGRAM ROPE RESCUE ACTIVITY
I, hereby affirm that I am the parent or legal guardian of First Name Last Name, who has signed the foregoing Waiver and Release of Liability and Indemnity Agreement and I consent to my child or ward to participate in the BCEMS Kids Camp Rope Rescue Program. I further state that I am of lawful age and legally competent to sign this Parental or Guardian Agreement on behalf of my child or ward. I have read and understand both this Agreement and Consent and the Waiver and Release of Liability Agreement signed by my child or ward. By signing this document, I agree and understand that my child or ward has waived and released liability, and agreed to indemnify Butler County, for himself/herself and his/her heirs and assigns which includes me. I have fully informed myself of the contents of this event and associated documents by reading them before I have signed below.
Name of parent or Guardian

First NameLast Name
Signature
Date

MonthDayYear
Date

PAYMENTS CAN BE MADE BY CALLING 322-4262 DURING NORMAL BUSINESS HOURS. Cash or check can be paid in person or mailed to 701 N Haverhill Rd El Dorado Ks 67042- Checks are made payable to Butler County EMS PLEASE INDICATE HOW YOU WISH TO PAY*
Payments will be processed by EMS billing department. Payments are $100.00 for 1 camper IF YOU ARE REGISTERING MULTIPLE CAMPERS, RECIEVING FINACAL ASSISTANCE, A COUNTY EMPOYEE OR ORDERING ADDITIONAL T-SHIRTS PLEASE CALL THE BILLING OFFICE AT (316)322-4262
Should be Empty:

Medical History Form

Firearm Safety Demonstration Waiver

PARENT OR GUARDIAN AGREEMENT AND CONSENT TO WAIVER AND RELEASE OF LIABILITY AND INDEMNITY AGREEMENT FOR THE BUTLER COUNTY EMS (BCEMS) KID'S CAMP PROGRAM ROPE RESCUE ACTIVITY