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DSA Kids Camp August 1st-August 5th
Parent/Guardian 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
Country
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Camper Information
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First Name
Last Name
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(mm/dd/yyyy)
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Help us get to know your camper!
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Camper Medical Information/Health History
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Bathroom Information
Please skip this section if your child is fully potty trained and manages bathroom skills completely independently.

Emergency Contact #1
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First Name
Last Name
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Emergency Contact #2
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First Name
Last Name
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Camp Waiver
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General Waiver - By stating "yes," I hereby grant the DSA of the Midlands permission to use the camp participant’s likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.I hereby irrevocably authorize the DSA of the Midlands to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein the student’s likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge the DSA of the Midlands from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.By stating "yes" to this agreement, I release Down Syndrome Alliance of the Midlands from all liability relating to illness or injuries that may occur during DSA events, activities, and classes. By saying "yes" to this agreement, I agree to hold DSA of the Midlands entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence.I agree to hold DSA of the Midlands entirely free from any liability, including financial responsibility for injuries incurred if any emergency medical treatment is administered by staff or agency volunteers.
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