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Summer Day Camp Registration Form

July 27th - July 31st 

9am - 12pm

Ages 8 - 13 years old 

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1. Child's Information
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First Name
Last Name
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(mm/dd/yyyy)
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2. Child's Information
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First Name
Last Name
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(mm/dd/yyyy)
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3. Child's Information
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First Name
Last Name
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(mm/dd/yyyy)
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Primary Parent/Guardian's Contact Information
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Secondary Parent/Guardian's Contact Information

First Name
Last Name



Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code


Medical Treatment Authorization

In the event that my child needs immediate medical attention for injuries received while participating in a program at the DANA Adobe & Cultural Center, I give my permission for the Dana Adobe Nipomo Amigos Inc. and DANA Adobe & Cultural Center staff and volunteer members to administer necessary medical treatment. Dana Adobe Nipomo Amigos Inc. and DANA Adobe & Cultural Center staff and volunteer members may also admit my child to a hospital emergency room for emergency medical treatment without my consent if I cannot be reached to give permission.

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Parent Authorization
Medical & Liability Release 

The undersigned agrees to hold the Dana Adobe Nipomo Amigos Inc., any officer, employee or volunteer thereof harmless from any claim for injury or accident to the above-named child/children arising out of or in any way connected with the named activity. I recognize that this program may have some inherent risks and I accept the responsibility to identify those risks and accept them. In case of an accident arising out of an activity, medical assistance may be administered to the person named herein. This registration form will act as a medical release. If the participant is under 18, a parent or guardian must sign a release.

Official Nondiscrimination Statement

Dana Adobe Nipomo Amigos Inc. does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, and clients.

 

Photo Release Waiver

I give Dana Adobe Nipomo Amigos Inc. and DANA Adobe & Cultural Center permission to publish in print, digital, or video format the likeness or image of my child. I release all claims against Dana Adobe Nipomo Amigos Inc. with respect to copyright ownership and publication including any claim for compensation related to use of the materials.

I hereby consent and agree that Dana Adobe Nipomo Amigos Inc., its employees or volunteers, or agents have the right to take and use photographs, videotape, audiotape or digital recordings of my child while on the Dana Adobe Nipomo Amigos property to be utilized in the development of marketing materials not limited to newsletter, website, emails, press releases, and/or TV.

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Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Dana Adobe Nipomo Amigos Inc. and DANA Adobe & Cultural Center (“DANA”) has put in place preventative measures to reduce the spread of COVID-19; however, DANA cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending DANA Summer Day Camp at DANA could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending DANA Summer Day Camp at DANA and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by attending DANA Summer Day Camp at DANA may result from the actions, omissions, or negligence of myself and others, including, but not limited to, DANA employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance to DANA Summer Day Camp at DANA or participation DANA programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless DANA, its employees, volunteers agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of DANA , its employees, volunteers, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in DANA Summer Day Camp at DANA.

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Registration non-refundable after July 13th

Payment is due upon registration or your campers spot will not be saved