PLEASE PROVIDE INFORMATION ON THE CAMPER

PLEASE SELECT YOUR REQUESTED DAYS/WEEKS

We recommend the following Schedules:

Every Day (where applicable)

3 or more time per week (where applicable)

Single day registration offered on a case by case basis only

9:00 AM - 2:00 PM

Emergency Contact 1

Emergency Contact 2

Tell us more about your Camper

*PLEASE NOTE: If new to Adrian's Place, we may reach out to follow up by phone so that we may learn more about your camper.

Payment Information

Registration Forms & Payment must be turned in before participation in any activity.

If you are a Regional Center client, contact your service Coordinator and add Adrian’s Place Santa Monica for Camp (Purchase order must be received from your Regional Center prior to participation)

I give permission to Adrian’s Place Santa Monica for my child/charge (“camper”)  to be transported by walking and/or by public transportation to an event at a specified location on a date indicated prior to a field trip or off-site event. I understand that my child is expected to follow all applicable laws and to follow the directions provided by the driver and/or other adult staff and/or volunteers. I understand that participation in an identified event is not a requirement for participation in the Adrian’s Place Santa Monica program.

 I have read, understand, and discussed with my child that:

1. They will be traveling by walking and/or public transportation.

2. They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip;

3. Riding in a motor vehicle may result in personal injuries or death from accidents, collisions or acts by riders, other drivers, or objects; and

4. They are to remain in their seats and not be disruptive to the driver of the vehicle.

I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss.

I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

As a condition for the transportation received, I, for myself, my child/charge, my executors and assigns, further agree to release and forever discharge Adrian’s Place Santa Monica, its owners, operators, employees and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.

As consideration for permission to enter onto the real property located 1806-1808 Lincoln Blvd., Santa Monica, CA 90404 (“Property”) to attend various gatherings, including but not limited to, time before and/or after an activity, unorganized free time, participation of any organized recreational, educational or therapeutic activity, movie nights, potlucks or other similar social gatherings organized by or in association with Adrian’s Place Santa Monica, LLC, (“Company”) the undersigned acknowledges, appreciates, willingly and with full knowledge, agrees that:

1. Entering onto the Property inherently includes possible dangers, including but not limited to personal injury, and possible death, damage to personal property or exposure to and illness from infectious diseases, including but not limited to MRSA, influenza, and COVID-19. While rules and personal discipline may reduce this risk, the risk of serious illness and death does exist; and,

2. I, ON BEHALF OF MYSELF OR FOR THE MINOR IDENTIFIED BELOW, KNOWINGLY AND FREELY ASSUMES ALL SUCH INHERENT RISKS, both known and unknown, EVEN IF ARISING FROM THE ACTIVE OR PASSIVE NEGLIGENCE OF others, and assumes full responsibility for participation; and,

3. I recognize the importance of complying with, and I will ensure that I or the Minor fully complies with, any applicable laws, policies, rules, instructions, and posted warnings entering on to the Property. Minor and I understand that if we believe anything on the Property may be unsafe, we will advise a Company representative and may refuse to enter on the Property. Entering onto the Property and remaining on the Property shall constitute consent to these terms. 

4. On behalf of myself or the Minor, HEREBY RELEASE AND HOLD HARMLESS the Company, directors, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors, advertisers, WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE ACTIVE OR PASSIVE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law. Further I or on behalf of the Minor agree to defend the Company for any and all claims, suits, allegations or action brought against the Company arising out of, relating to or based in any way out of such presence on the Property, regardless of the doctrine of comparative fault.

5. I agree that if any portion of this contract is held invalid, the remainder will continue in full legal force and effect. I understand and agree that the law of the state of California shall apply. I agree that all disputes shall only be brought in the State Court of California without regard to the choice of law doctrine. I agree to the personal jurisdiction of California to adjudicate any such dispute.