Clone of Kamp Kickapoo 2025 Registration Form

Which Kamp are Signing up for? (Kamper must be able to attend all 4 days).*

Kamp 1 (June 8-11)Kamp 2 (June 22-25). All entries after APR 30 will be placed on the standby list

Kamper Information

Kamper's Name*

First NameLast Name

Birth Date*

MonthDayYear

Kamper's Tribal Affiliation(s)*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number*

Format: (000) 000-0000.

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Alt. Phone Number*

Format: (000) 000-0000.

Emergency Contact's Name

First NameLast Name

Alt. Phone Number

Format: (000) 000-0000.

Emergency Contact's Name

First NameLast Name

Alt. Phone Number

Format: (000) 000-0000.

Select Child's T-Shirt Size*

Select Child's Shorts Size*

Does the Kamper have any allergies, chronic illness, or medical conditions? If yes, please describe. If none, write in "none."*

Is the Kamper prescribed an inhaler or other emergency remedy or device? If yes, please explain any instructions.

Informed Consent and Photo Release

I hereby give my approval for my child’s participation in any and all activities prepared by Kickapoo Tribal Health Center during the selected camp. In exchange for the acceptance of said child’s candidacy by Kickapoo Tribal Health Center., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Kickapoo Tribal Health Center and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

I, hereby, grant to Kickapoo Tribal Health Center and its Health Promotion and Disease Prevention Department the absolute and irrevocable right and unrestricted permission to publish, distribute, exhibit, or otherwise use the photographs that Photographer's Name has taken or may have taken of my child. I hereby release the photographer from all claims, demands, and liabilities whatsoever in connection with the photographs. I understand that the images may be modified in any manner, and I hereby waive any right to inspect or approve any final product that uses photographs. I acknowledge that the images may be used, without limitations, in print publications, online publications, websites, and on social media.

In case of injury to said child, I hereby waive all claims against Kickapoo Tribal Health Center and it's staff members, including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports or physcial activities, including games. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named child, 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 athlete. 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 Kickapoo Tribal Health Center and its affiliates including Directors, Staff, Volunteers and Counselors 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 season.

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.

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.

Signature

Kamp Kickapoo Registration