2015 Ranger Camps - Forest Preserve District of DuPage County

2015 Ranger Camps
Camp Information
• Please complete both sides of this form, and submit a separate form for each participant.
• Submit your form, waiver and payment by fax to (630) 933-7217 or in person at Visitor Services, Forest Preserve District
Headquarters, 3S580 Naperville Road, Wheaton, IL 60189. Sessions fill on a first-come, first-served basis.
• For special accessibility needs or concerns, call the Forest Preserve District’s ADA coordinator at (630) 933-7683 or TTY (800) 526-0857 at least three weeks before the start of your session.
• Questions? Call Visitor Services at (630) 933-7248.
Participant Information
Participant’s Name
Age
Parent or Legal Guardian’s Name
Preferred Phone
Alternate Phone
Email for confirmations only
Street Address
City
State
Zip
DuPage County Resident? ❍ Yes ❍ No
Emergency Contact if parent or guardian is unavailable
Name
Preferred Phone
Alternate Phone
Doctor
Phone
Date of Last Tetanus Shot
Allergies
Other Medical Conditions
Medications Staff cannot dispense. Parent or guardian must arrange.
How did you hear about this program?
T-Shirt ❍ Youth XS ❍ Youth S ❍ Youth M ❍ Youth L ❍ Youth XL ❍ Adult S ❍ Adult M ❍ Adult L ❍ Adult XL
Fees and Schedules
Ranger Adventure Camp Ages 9 – 12 (grades 4 – 8)
____
____
____
____
____
____
June 15 – 19
June 22 – 26
June 29 – July 3
July 6 – 10
July 6 – 10
July 13 – 17
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
Ranger Leadership Camp Ages 13 – 17
____ June 27 – 31
9 a.m. – 3 p.m.
DuPage County resident $200
Herrick Lake
Herrick Lake
Herrick Lake
Herrick Lake
Mayslake
Herrick Lake
____
____
____
____
____
____
July 13 – 17
July 20 – 24
July 20 – 24
July 27 – 31
Aug. 3 – 7
Aug. 10 – 14
DuPage County resident $300
Herrick Lake
1
Nonresident $250
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
9 a.m. – 3 p.m.
Nonresident $350
Mayslake
Herrick Lake
Mayslake
Mayslake
Mayslake
Mayslake
Participant Waiver, Release, Hold Harmless and Indemnification Agreement
a) I voluntarily waive, release, and hold harmless the District, its elected officials, officers, employees, agents, and other volunteers, from
any and all claims, causes of action and damages for bodily injury or death that I may suffer as a result of, or in any manner connected
with, directly or indirectly, my participation in “Ranger Adventure Camp” or “Ranger Leadership Camp” that includes but is not limited
to forest preserve exploration, camping skills development, archery, fishing and boating in DuPage County. I understand that this waiver
and release precludes my right to recovery of damages in the event I am injured in the course of my participation in “Ranger Adventure
Camp” or “Ranger Leadership Camp” held at Herrick Lake Forest Preserve and Mayslake Forest Preserve in DuPage County.
b) I shall defend, hold harmless and indemnify the Forest Preserve District of DuPage County, its elected officials, officers, employees,
agents and other volunteers, from and against all damages, claims, liabilities, causes of action, judgments, settlements, costs and expenses
(including, but not limited to, reasonable expert witness and attorney fees) that may at any time arise or be claimed by any person,
including minors who in my charge, or my responsibility, and who would be represented by a parent, next friend or guardian including
myself, as a result of bodily injury, death or property damage, or as a result of any other claim or cause of action of any nature
whatsoever, arising from or in any manner connected with, directly or indirectly, my negligent or intentional acts or omissions in my
participation in “Ranger Adventure Camp” or “Ranger Leadership Camp” held at Herrick Lake Forest Preserve and Mayslake Forest
Preserve in DuPage County.
I have read, fully understand and agree to the assumption of risk, waiver, release, hold harmless and indemnification terms set forth above.
Participant’s Printed Name
Parent or Legal Guardian’s Printed Name
Parent or Legal Guardian’s Signature Date
Cancellations
To receive a refund minus a $25 administrative fee, you must cancel at least 21 days before the first day of your session. The Forest
Preserve District will not issue any refunds after this deadline. If the Forest Preserve District needs to cancel a session due to severe
weather, power failure, lack of adequate enrollment, instructor illness or other reason, you may apply your fee to another session if space
is available. Otherwise, the Forest Preserve District will process a refund within 30 days of notification.
Payment Information
❍ Cash Please do not mail cash.
❍ Check payable to Forest Preserve District of DuPage County
❍ Visa
Card Number
❍ MasterCard
Amount to Charge $
❍ Discover
Name on Credit Card
Signature
Exp. Date
2
Billing Zip Code