EmailMe Form - Waitlist: 2017 Eastside Express Summer Camp

Child's Name *

First Last

Age

Date of Birth (6 digits only, i.e. 040707) *

Grade Going Into *

Has your child been to ESX Before? *

Yes

No

If this is your first year, how did you hear about ESX?

Please list child's allergies (if any):

Emergency Contact Information

Please enter the name of two parents or guardians who should be contacted in the case of an emergency.

Name *

First Last

Relationship *

Day Phone *

### - ### - ####

Cell Phone: *

### - ### - ####

Email *

Name *

First Last

Relationship *

Day Phone *

### - ### - ####

Cell Phone *

### - ### - ####

Email *

Child's address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Eastside Express offers weekly fieldtrips and appreciates parents assisting when possible. Please indicate below if you are interested in being a volunteer for one or more field trips. *

Yes, I'd like to learn more.

No thanks, I'm busy as it is!

Informed Consent, Hold Harmless/Release Agreement and Photo Permission Form:
I understand that participation in camp activities involves a certain degree of risk. I have carefully considered the risk involved and have given consent for my child to participate in these activities. I understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. By listing my initials below, I release the Marquette Neighborhood Association, Wil-‐Mar Neighborhood Center, Eastside Express, the activity coordinators, counselors, director and all volunteers associated with Eastside Express camp activities from any and all claims of liability arising out of this participation. I also agree, by listing my initials below, that my child may participate in the weekly fieldtrips. Finally, I understand that photos may be taken during camp for educational and marketing purposes. By listing my initials below, I give my consent for my child to be photographed and for any photos to be used to promote Eastside Express, the Wil-Mar Neighborhood Center, and the Marquette Neighborhood Association. *