Zoo Camp Application Packet

DADE CITY’S WILD THINGS

SUMMER CAMP APPLICATION (2017)

zoo camp packet 2017

Name _____________________________________________________________________

 

DOB ________________________________ Shirt Size ______________________

 

Address ___________________________________________________________________

 

City _________________________________________________ ZIP Code _____________

 

Home Phone __________________________ Work Phone __________________________

 

Mobile Phone __________________________ Other Phone _________________________

 

Parents / Guardians____________________________________________________________

 

E-mail Address _______________________________________________________________

 

Emergency Contact Name: ______________________________________________________

 

Phone(s): __________________________________________________________________

 

Name(s) of Persons Authorized to Pick Up Child:

 

Name: __________________________________ Phone: ______________________________

 

Name: __________________________________ Phone: ______________________________

 

Medical Conditions: ____________________________________________________________

 

Allergies to Foods: ____________________________________________________________

 

Alergies to Medications: ________________________________________________________

 

Insurance Company: ___________________________________________________________

 

Policy # _______________________ Insurance Company Phone: _______________________

 

Physician Name: ____________________________________________

 

Physician Phone: ___________________________________________

 

Under medical care? _______ Why?_______________________________________________

 

Taking medications? _______ Why?_______________________________________________

 

Special Instructions? ___________________________________________________________

 

___________________________________________________________________________

 

_____ One Day Camp ($85.00) Total Amount Due: ______ Payment Method

 

_____ Three Day Camp ($175.00) Total Amount Paid: ________ CASH ______ CHECK

 

_____ Pre-School Camp ($20.00) Date Requested: ________________ CREDIT CARD: ________

 

If paid after June 10, 2017 an additional $20.00 fee will apply

Date Shirt Given: __________    Shirt Size Given: ________   Date CD Mailed: ____________

 

 

 

 

Release of Liability for Zoo Camp

Read Carefully before signing

I, __________________ /or guardian ____________________, in consideration for being permitted to participate at the Dade City’s Wild Things Zoo Camp, hereby release and discharge Dade City’s Wild Things, Stearns Zoological Rescue & Rehab Center Inc, Kenneth & Kathryn Stearns and their respective officers, directors, employees, agents, contractors, subcontractors, representatives, successors, and assigns, and all persons conducting, directly or indirectly, the activities surrounding involvement as a Zoo Camp Participant at Dade City’s Wild Things from any or all claims, rights, demands, actions, causes of actions, expenses, damages, which I or my heirs, personal representatives, successors, assigns or anyone claiming by, through or under me ever had, now have, or may have against the parties identified above arising from any injury, act or omission relating in any way to my participation in Zoo Camp.

I fully understand that this release includes, but is not limited to any claims, rights, demands, actions, cause of actions, expenses and damages whatsoever which may arise from any injury, act or omission, caused, occasioned, or contributed to, actually or allegedly, by the negligence, sole or concurrent, of one or more parties released herein.

I also fully understand the risk involvement in my participation in Zoo Camp including, but not limited to, those risks involved with the working with wild and/or endangered animals in their habitats, and fully assume said risk for any injury, losses or damages of any kind resulting from such risks involved in associated activities. I agree that I will not allow any animals to be put to death for any type of testing if I am injured. I agree to rabies vaccines instead of requiring the animal to be killed for testing. I also fully authorize any emergency medical treatment needed in an emergency situation releasing and discharging any and all medical personnel as well as the above-mentioned arising from any injury, act or omission relating in any way to my participation in Zoo Camp.

By paying and Participants you are releasing Dade City’s Wild Things/Stearns Zoological Rescue & Rehab Center Inc. and all its subsidiaries from all liability for injury resulting from bites, scratches, ringworm, and injury from rough play with any animals or any swimming activities. I realize that these animals are subject to rough play and that there is a possibility of damage to me, my kids or to clothing or other articles taken in cage with me. I agree that I will not allow any animals to be put down for any type of testing if I am injured. I agree to rabies vaccines instead of requiring the animal to be killed for testing. I understand that these animals are not pets but exotic animals with their own personalities and reactions. I agree to not touch or attempt to pet any animal outside of the encounter areas.

I agree to abide by all instructions and follow all safety precautions hereby given by the staff of the Dade City’s Wild Things. The staff, officers, directors, volunteers are well trained and to the best of their abilities will try to control the situation for the safety of guests and animals. I agree to respect all barriers and rules. I understand that these animals are not pets but exotic animals with their own personalities and reactions and there is always a risk.

I also understand all photos taken are owned and are the property of Dade City’s Wild Things solely.

By paying you agree to these terms and understand that all photo can be used for professional, internet, media, activist use, competitors, news articles, or for any other reason except for your immediate personal use. No photos can be used for PETA, HSUS, BCR or any activist use or propaganda. No Exceptions.

At no time do we agree or allow videos to be recorded for any reason.

I acknowledge that I have read, fully understand and voluntarily agree to this release and that no oral representatives, statements or inducements apart from this Release have been made to me.

 

 

MEDICAL SECTION

Do you have any medical conditions? _____ NO _____ YES,

Explain: ____________________________________________________________

 

Do you have any allergies? _____ NO _____ YES,

Explain: ____________________________________________________________

 

Are you under medical care? _____ NO _____ YES,

Explain: _____________________________________________________________

Date ___________ Participant Signature  ___________________________ Age ________

 

Print name ______________________  Participant Date of Birth  ______________

Date Parent or Guardian (if under 18) ____________________________________

Contact Phone No – 1 _____________________

 

Print Name – Parent or Guardian _______________________________________

Contact Phone No – 2_______________________

 

Date ___________  Witness Signature  __________________________________

Print Name of Witness________________________________

 

Date ___________ Witness Signature  ___________________________________

Print Name of Witness  _______________________________