EmailMe Form - Waitlist:2019 Eastside Express Registration

EmailMeForm

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):
Which weeks do you hope to have your child attend camp? *
First Week
Second Week
Third Week
Fourth Week
Fifth Week
Sixth Week
Emergency Contact Information
Please enter the name of two parents, grandparents or guardians who should be contacted in the case of an emergency.
Emergency Contact #1 *
First Last
Relationship *
Day Phone *
### - ### - ####
Cell Phone: *
### - ### - ####
Email *
Emergency Contact #2 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
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 typing my name 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 name below, that my child may participate in the weekly fieldtrips to BB Clark Beach and Rutabaga. 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. *
Type Name Above

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