Summer Adventure Camp Participant Permission and Release

A release form must be completed and submitted for each Summer AdventureCamp participant. Pre-register the camper by phone or email before the deadline. Return form and full payment to the museum 10 business days prior to the camp.

Please Print

Participant’s Name ______Date of Birth ______Male Female

Parent/Guardian Name ______

Address ______

PhoneHome ( ) ______Cell ( ) ______

Employer ______Work ( ) ______

Email ______

Emergency Contact Name and Relation ______

Emergency Contact Phone ( ) ______( ) ______

Physician’s Name ______( ) ______

Any allergies, special needs or special dietary needs? ______

______

Immunizations current? Yes No

Please check boxes to indicate your agreement:

My child is physically fit and able to participate in camp activities.

My child has permission to participate in any camp field trip(s) under supervision of Museum staff. My child can participate in recreational activities provided during the camp. Some of these activities may require additional waivers from providers or outfitters. I will receive a field trip itinerary and additional waivers prior to the start of the camp. My child has permission to walk to the Frank Wilson Park (behind the Museum) under supervision of Museum staff for outdoor activities and/or to have lunch (weather permitting).

I will sign-in and sign-out my child daily. Authorized adults that can pick-up my child include:

1)______2) ______

My child will abide by the rules and regulations of the Museum and obey the direction of the Museum’s staff. I will be notified if there are discipline problems and understand that s/he can be dismissed from camp with no refund.

Video and/or photography may be used to document camp events. I agree that the Museum shall be the exclusive owner of the video/photography. I grant full and irrevocable consent to the Museum and those acting under its permission or upon authority, the unqualified right and permission to reproduce, copyright, publish, or otherwise use photographic likeness.

*Please initial if you DO NOT give permission for video/photography. ______

I understand that neither medical nor health insurance coverage is supplied by the Museum and that the participant is responsible for all insurance coverage.

I authorize VMNH to arrange any emergency medical care in the event I cannot be reached.

I release from liability, and promise not to sue the Commonwealth of Virginia, the Virginia Museum of Natural History, the Virginia Museum of Natural History Foundation, or the officers, agents, or employees of either, for the injury or property damage that I may suffer while participating in the program in any way, unless such injury or property damage is caused by the gross negligence or intentional misconduct of the Museum.

Signature of Parent/Guardian______

Signature Date

2015 Summer Adventure Camps

Camper’s name: ______

Museum member: Yes No

Select the camp(s) the camper is registering for:

/ Camp / Age / Date – Time / Registration
Deadline / COST
Who Done It? / 6 - 8 / June 1 – 5 9 a.m. – 4 p.m. / May 15 / $95 Member $105 NonMbr
Go With the Flow / 9 - 11 / June 1 - 5 9 a.m. – 4 p.m. / May 15 / $105 Member
$115 NonMbr
Doodle Bugs! Camp Out / 3 – 5 (w/adult) / June 3 – 5 9:30 – 11:30 a.m. / May 20 / $30 Member
$35 NonMbr
Nature Rangers / 6 - 8 / June 8 – 12 9 a.m. – 4 p.m. / May 22 / $95 Member $105 NonMbr
Adventure Egypt / 6 – 8 / June 15 – 19 9 a.m. – 4 p.m. / May 29 / $95 Member $105 NonMbr
Mad Scientist Club / 9 - 11 / June 15 - 19 9 a.m. – 4 p.m. / May 29 / $95 Member $105 NonMbr
Doodle Bugs! Change is Coming / 3 – 5 (w/adult) / June 24 - 26 9:30 – 11:30 a.m. / June 10 / $30 Member
$35 NonMbr
Super You / 6 – 8 / June 29 – July 3 9 a.m. – 4 p.m. / June 12 / $95 Member $105 NonMbr
Earth Explorations / 9 - 11 / June 29 - July 3 9 a.m. – 4 p.m. / June 12 / $95 Member $105 NonMbr
Junior Naturalists / 9 - 11 / July 6 – 10 9 a.m. – 4 p.m. / June 19 / $95 Member $105 NonMbr
Doodle Bugs! Summer Splash / 3 – 5 (w/adult) / July 8 - 10 9:30 – 11:30 a.m. / June 24 / $30 Member
$35 NonMbr
POWwow / 6 - 8 / July 13 - 17 9 a.m. – 4 p.m. / June 26 / $105 Member
$115 NonMbr
Museum Mayhem / 9 - 11 / July 13 – 17 9 a.m. – 4 p.m. / June 29 / $105 Member
$115 NonMbr
Junior Engineering / 9 - 11 / July 20 – 24 9 a.m. – 4 p.m. / July 3 / $105 Member
$115 NonMbr
Doodle Bugs! Construction Zone / 3 – 5 (w/adult) / July 22 – 24 9:30 – 11:30 a.m. / July 8 / $30 Member
$35 NonMbr
Forensic Detectives / 9 – 11 / July 27 – 31 9 a.m. – 4 p.m. / July 10 / $95 Member $105 NonMbr
Camp Bug Out / 6 – 8 / July 27 – 31 9 a.m. – 4 p.m. / July 10 / $95 Member $105 NonMbr
Build That / 6 – 8 / August 3 – 7 9 a.m. – 4 p.m. / July 17 / $95 Member $105 NonMbr
Doodle Bugs! Sense Scientists / 3 – 5 (w/adult) / August 5 – 7 9:30 – 11:30 a.m. / July 22 / $30 Member
$35 NonMbr

Please note:

  • Pre-register before the deadline by phone or email (see below).
  • Registration deadline is ten (10) days prior to the start of the camp. All camp forms and payment are due by the deadline. If paying by check, please post-date the check for the first day of camp. If applying for a scholarship, submit the scholarship application with the permission form by the deadline.
  • A minimum of eight (8) camp participants are required in order to conduct a camp.
  • Participants will be notified after the registration deadline if a camp will be cancelled.
  • If selecting lunch and before/after care, complete the form, include payment, and attach to camp permission/release form by the deadline.

If there are any questions, please contact the education department at 276-634-4185 or email .