HSWM Spring Break Camp
An engaging camp for animal lovers to learn about companion pets filled with activities, games, crafts and animals! We will provide age-appropriate activities for campers of all ages. Recommended ages 5-12.
Child's Name:
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First Name
Last Name
Child's Age:
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Child's Date of Birth:
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Returning Camper?:
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Yes
No
Parent/Guardian Name(s):
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First Name
Last Name
Phone Number:
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Email:
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example@example.com
Emergency Contact (if you are not available):
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First Name
Last Name
Relationship:
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Emergency Contact Phone Number:
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Please enter a valid phone number.
Name(s) of those authorized to sign OUT a camper:
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Medical Considerations (allergies, physical, or behavior limitations, etc.):
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Spring Break Camp Monday
April 7th, 9-4pm
$
65.00
Spring Break Camp Tuesday
April 8th, 9-4pm
$
65.00
Spring Break Camp Wednesday
April 9th, 9-4pm
$
65.00
Spring Break Camp Thursday
April 10th, 9-4pm
$
65.00
Spring Break Camp Week
April 7-10, 9-4pm
$
250.00
Camp Tie-Dye Drawstring Bag
$
10.00
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Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Release, Waiver of Liability and Indemnification Agreement.
Please sign the below to accept our terms & conditions.
In consideration for my (our) child above being permitted to participate in Humane Education Camp activities provided by Humane Society of West Michigan, its employees, agents, volunteers, and/or affiliates (collectively referred toas “HSWM”), I (we), agree to the following: I understand that my child will be interacting with unfamiliar animals throughout the term of the summer camps. I certify that there are no physical, emotional, or mental problems or limitations associated with my child’s participation in these or any other camp activities. While the Summer Camp animals have been temperament tested by HSWM and HSWM in good faith believes the animals will be safe for interaction with the public, animals by their nature are unpredictable and there are many factors that can affect their behavior. HSWM will have complete discretion in determining how to react in all circumstances including unpredictable animal behavior. I understand that there are unpredictable risks and dangers inherent to interacting with any animal. For myself and my child, I acknowledge and assume the risks involved in these inherently dangerous activities, and for any damage; illness; injury; including, without limitation, animal bites, lacerations, or scratches; or death resulting from such activities. I certify that I have the authority to enter into this agreement on behalf of my child and release and waive any claims that I or my child may have against HSWM with respect to any loss; injury, including, without limitation, animal bites, lacerations, or scratches; illness; damage; or death occurring to my child while he/she is in the custody and care of HSWM as well as any related claims that I may have. I agree to indemnify and hold harmless HSWM from and against any and all liability and costs (including attorney fees) related to any such claim asserted against HSWM by or on behalf of my child or me. I agree that this release, waiver of liability and indemnification agreement is intended to be as broad and inclusive as permitted by the laws of the of Michigan, and that if any portion there of is held invalid, it is agreed that the balance shall not with standing continue in full legal force and effect. In the event of an accident or injury to my child, I authorize HSWM to make whatever transportation, diagnosis, and/or treatment arrangements as they, in their sole discretion, deem to be appropriate in the circumstances. I agree that my insurance or I personally will be liable for any costs incurred for the transportation, diagnosis, and/or treatment of my child. Transportation, diagnosis, and/or treatment of my child should proceed whether or not I can be contacted. Below I am providing my contact phone number(s) and HSWM is not responsible to identify any other means to contact me if that is unsuccessful. I grant HSWM the right to use my name, portrait, photograph, video segment, likeness, or other image, and those of any minor named below, on whose behalf I am signing, for marketing, public relations, and/or educational purposes. I grant HSWM the right to use the name or image described above in print, video and/or electronic media. I understand that HSWM retains all rights to use, publish or distribute the portraits, photographs, video segments, likenesses, or other images and has the right to do so without seeking any further permission from me or providing me any royalty. I understand that notification is not a condition to HSWM’s use or publication of my name or image for marketing, public relations and/or educational purposes. I understand that full refunds may only be provided with three week’s full notice of cancellation, prior to your scheduled attendance, minus a $50 processing fee. I understand that refunds will not be provided without notice of cancellation and that refunds cannot be provided during the scheduled week of camp. Please Note: Animal time during camp may be limited or varied depending on the day, the camp, and what animals we have at the time. Shelter animals are in an extremely stressful environment, and our goal is to provide the campers and animals with a safe and enriching experience. We appreciate your patience and understanding as we all strive to provide shelter animals and campers a safe environment. I HAVE READ AND UNDERSTAND THE ABOVE AND AGREE TO BE BOUND BY THE TERMS OF THIS DOCUMENT.
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Insurance Provider:
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Policy #:
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Child's Physician:
*
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Please review this information with your child (all children regardless of age!) and have them sign below.
I understand that I am here to learn more about Humane Society of West Michigan and how to be a responsible, caring friend to animals. I will do my best to follow instructions and to act in such a way as to protect the animals and the people around me. I also agree to behave myself in a responsible way. I understand the discipline policy. 1. What is the camp discipline policy? a. Disciplinary action may be taken if a camper displays behavior that disrupts the camp program. Examples of this behavior include inappropriate language, making fun of or insulting others, bullying, using profanity, harming or frightening the animals, physically harming others, not following directions or actions that make animals, instructors, or other campers feel uncomfortable. b. In general, the consequences for undesirable behavior will follow these steps: i. First offense- verbal warning from staff ii. Second offense- partial removal from activity; follow up with parent/guardian iii. Third offense- sent home and meet with parent/guardian iv. Fourth offense- Removal from camp; no refund given However, if HSWM staff or volunteers determine that my behavior is a danger to the animals, other campers, or anyone else at Humane Society of West Michigan, no warning will be given, and I will be sent home immediately. Campers Signature Below:
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Please verify that you are human
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