Make new friends, bring your old ones, and participate in awesome activities inthe Clubhouse andaround Chicago, includingthe Chicago Botanic Garden, Pump it Up,Wrigley Field, Funny Bonesand more!
Kids Camp 2016 Agenda
August 1
Kids Camp 2016 Agenda
August 1
9:00-9:30 Check in
9:30-10:30 Mixer Games
10:30-11:30 Art
11:30-12:00 Sparkle Time
11:45-12:00 Walk to Gino’s East
12:00-1:00 Lunch at Gino’s East
1:00-1:15 Walk back to Gilda’s Club Chicago (GCC)
1:15-2:00 Crafts
2:00-3:00 Creative Movement with Deb & Shango
August 2
9:00-9:30 Check in
9:30-10:30 Bus Ride to Chicago Botanic Garden
10:30-1:30 Succulent Dish Garden Activity,Grand Tram Ride, Lunch and Butterflies & Blooms Exhibit
1:30-2:30 Bus Ride back to GCC
2:30-3:00 Sparkle Time
August 3 (Late Day – we return to GCC by 4:00pm)
9:00-9:30 Check in
9:30-10:30Sparkle Time & Crafts
10:30-11:00 Bus Ride to Wrigley Field
11:00-3:30 Lunch and Chicago Cubs vs Miami Marlins Game
3:30-4:00 Bus Ride back to GCC
August 4
9:00-9:30 Check in
9:30-10:30Yoga with Patricia
10:30-11:30CircEsteem (Partner Acrobatics, Tight Wire, Plate Spinning & Feather Balancing)
11:30-12:30 Sparkle Time& Crafts
12:30-1:00 Lunch
1:00-3:00 George’s Gym
August 5
9:00-9:30 Check in
9:30-10:30 Mad Science – Movie Effects
10:30-11:00 Bus Ride to Pump it Up
11:00-1:00 Pump it Up (socks are required to jump on the inflatables)
1:00-1:30 Bus Ride back to GCC
1:30-2:30 Funny Bones
2:30-3:00 Sparkle Time, Popsicles, Goody Bags and Farewells
Camper Registration Form
Child’s Name: ______
Child’s Address:______City: ______Zip Code: ______
Child’s Telephone Number: (h) ______(c) ______
Child’s Email Address: ______
Child’s Date of Birth: ______Gender: ______
Parent/Legal Guardian(s) Name: ______
Parent/Legal Guardian(s) Email Address:______
Emergency Contact: ______
If not parent, relationship to child: ______
Emergency Contact Telephone Number: (h) ______(c) ______
Child’s relationship to the person with cancer ______
Child’s t-shirt size ______
Please list any allergies/medical conditions: (ex. asthma, diabetes, cancer, bee sting allergy, etc.) ______
Please list any other special concerns/considerations that you would like Gilda’s Club Staff to be aware of:
______
I give permission for my childto attend the Gilda’s Club Chicago’s Kids Camp August 1-5. I have reviewed the agenda and am aware of the activities that my child will be participating in throughout the week. I understand that Sparkle Time is an opportunity forthe kids to share their cancer experience with with each otherat designated times each day of camp. If you have any questions regarding Sparkle Time please contact Noogieland Coordinator, Liz Sullivan, LCSW. I understand that camp takes place at Gilda’s Club Chicago, located at 537 N. Wells Street Chicago, IL 60654. I understand my child will be riding a school bus to off-site locations including: Chicago Botanic Garden, Wrigley Field & Pump it Up. I understand that on Monday, August 1stmy child will be walking to Gino’s East where s/he will be walking a total distance of 0.2 miles (.1 miles both directions) to and from Gino’s East.
Please make sure to complete the attached waiver for Pump it Up and remember socks are required to jump on the inflatables. I also understand that on Wednesday, August 3rd the camp day will end LATE at 4:00pm, instead of 3:00pm.
Camp t-shirts will be distributed on the first day – they MUST be worn on offsite “community days” to participate, these camp days include: Tuesday (8/2), Wednesday (8/3) and Friday (8/5).
Please check one of the following:
I will pick my child up from Gilda’s Club Chicago at the end of camp each day (3:00PM).
My child will be taken home by ______(adult’s name) at the end of camp each day (3:00PM).
______
Signature of Parent/Guardian and DateRelationship to Child
______
Print Name of Parent/Guardian
Lunch Choices
Please indicate your child’s preference for lunch:
August 1st:Gino’s East (thin crust pizza)
Cheese Pepperoni Sausage
August 2nd:PotbellySandwich (includes chips & a cookie)
Turkey Ham Tuna Pizza
August 3rd: Wrigley Field Concession Stand
There will be a variety of food available – each child will receive $10 in Cubs Cash
August 4th: Panera Sandwich (includes pickle spear, chips & a cookie)
Smoked Turkey PB&J Tuna Salad Mediterranean Veggie
August 5th:Pump it Up Chicago (thin crust pizza)
Cheese Pepperoni Sausage
My child has the following dietary restrictions: (vegetarian, lactose intolerant, peanut free, Kosher)______
Publicity Release for Gilda’s Club Chicago
I, the undersigned hereby grant Gilda’s Club Chicago the right, license and privilege to use my child’s name, likeness, photograph, voice, biography and video likeness in such a manner as Gilda’s Club Chicago deems appropriate in order to promote, advertise, and publicize Gilda’s Club Chicago and its charitable activities.
______
Signature of Parent Date
PLEASE NOTE: IF YOU WANT TO LIMIT OR RESTRICT GILDA’S CLUB CHICAGO’S RIGHT OF PUBLICITY IN ANY WAY YOU MUST PLACE YOUR INITIALS ON THE SPACE PROVIDED BELOW AND STATE THE SPECIFIC LIMITATION OR RESTRICTION YOU DESIRE
The publicity is limited in the following respects:
______
Initials
Pump It Up®
Waiver, Release, Hold Harmless, and Indemnification Agreement
Rev. 15.02
As Consideration for being allowed to enter the play area and/or Participate in any party and/or program at Pump It Up the undersigned, on his or her behalf, and on the behalf of the Participant(s) identified below, acknowledges, appreciates, understands, and agrees to the following:
1: I represent that I am the parent or legal guardian of the Participant(s) named below or I have obtained permission from the parent/legal guardian of the Participant(s) named below to execute this agreement on their behalf.
______
Participant Name Date of Birth
______
Participant Name Date of Birth
______
Participant Name Date of Birth
______
Participant Name Date of Birth
2: I acknowledge and understand that there are known and unknown risks associated with participation in Pump It Up activities and the use of the play area, inflatable equipment and any and all other Pump It Up equipment, including but not limited to the Pop-In Playtime and Open play, which include but are not limited to: contusions, fractures, scrapes, cuts, bumps, paralysis, or death. 3: I, for myself and the Participant(s) named, willingly assume the risks associated with participation and accept that there are also risks that may arise due to OTHER PARTICIPANTS which I also willingly assume. 4: I agree that the Participant(s) named, and I shall comply with all stated and customary terms, posted safety signs, rules, and verbal instructions as conditions for participation in any Pop-In-Playtime and/or any other open play event at Pump It Up. 5: I, for myself, the Participant(s) named, our heirs, assigns, representatives, and next of kin agree to hold harmless, release, waive and indemnify the independent owner of this Pump It Up facility, PIU Holdings, LLC, their predecessors, parent, subsidiaries and affiliates, officers, and employees from any and all injuries, liabilities or damages from participation, except for those arising from the gross negligence or willful misconduct of Pump It Up. 6: I additionally agree to indemnify the independent owner of this Pump It Up facility, PIU Holdings, LLC, their predecessors, parent, subsidiaries and affiliates, officers, and employees for any defense cost or expense arising from any and all claims, injuries, liabilities or damages arising from participation, except for those arising from the gross negligence or willful misconduct of Pump It Up. 7: I am of physical ability to participate and am legally competent to understand and complete this agreement. I hereby execute this agreement without coercion. 8: I understand that entry, by myself and the participant(s) named, constitutes consent for Pump It Up to use any film, video, or likeness of participants for any purpose whatsoever, without payment to the participant. 9: The invalidity or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision of this Agreement, which shall remain in full force and effect. 10: Any controversy, dispute, or claim arising out of or related to this Agreement, which the parties are unable to resolve by mutual agreement, shall be settled exclusively by submission by either party of the controversy, claim or dispute to binding arbitration; said arbitration to take place exclusively before a single arbitrator located within 25 miles of the Event location and in accordance with the rules of the American Arbitration Association then in effect.
Parent / Guardian Name (please print): ______
Parent / Guardian Signature: ______Date:______
Address: ______
City: ______ST:______Zip:______
Emergency Contact number: ( ) ______or ( ) ______
Email address: ______
By providing your e-mail address you acknowledge we may send you e-mail including Discount offers, special events, and Pump It Up news.