OHIO STATE UNIVERSITY EXTENSION

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1 OHIO STATE UNIVERSITY EXTENSION SUMMER 4-H CAMP WHERE DREAMS COME TRUE Registration Form June 3-7, 2019 Office Use Only Payment: Cabin: Team: Camper Name_ Home Address Gender Date of Birth Grade in School Age Camp Fees & Off-Site Events: $200 due May 15 OR until camp is full (Late registration May is $225) Camp T-shirt if registered by May 15. Select shirt size: Youth S M L XL Adult S M L XL Ziplining at Camp Ozone, June 4 (off-site & optional) $70 Bowling at Royal Z Lanes, June 5 (off-site & optional) $20 Morgan s river rafting, June 6 (off-site & optional) $25 *Camp group photo is included with all camp registrations. Total Enclosed -Camperships are due May 10 -Make Checks payable to Clinton County 4-H Committee -Registration will be accepted until camp is full. (This could be before the May 15 deadline.) -Only complete registrations will be accepted. -No multiple camper discounts. -Off-site/on-site activities can t be added after May 15. Return the registration & health form, off site activity waivers(s), transportation form and the camp fees by May 15 to: OSU Extension, 111 S. Nelson Ave, Suite 2, Wilmington OH (937) Only complete registrations (all forms, photo & signatures) will be accepted. Scholarship forms are available at the Extension Office or online at clinton.osu.edu for families with financial need. Campership forms are due to OSU by May 10. Please note: Campers and counselors may not have cell phones or other devices with online access. Campers may bring ipods, radios, etc. for use in the cabins, but camp is not responsible for lost or stolen items. Campers may have food in cabins, but please have it in a sealed container. No silly string at camp. Cabin Sign Up: Please have your child list two peers they would like to room with at camp and the camp staff will try to place your child with at least one of the names. The camp staff will try to place all campers by AGE in cabins with teen counselors. 1) 2) 4-H Registration Form _ Ohio 4-H Health Statement with Photo _ Camp Fee $200 ($225 late) _ Ziplining at Camp Ozone Waiver _ Ziplining Permission to Transport _ Ziplining Fee CAMP REGISTRATION CHECKLIST _ Morgan s Rafting Permission to Transport _ Morgan s Rafting Waiver _ Morgan s Rafting Fee Bowling Fee _ Bowling Permission to Transport Clinton.osu.edu CFAES provides research and related educational programs to clientele on a nondiscriminatory basis. For more information: go.osu.edu/cfaes

MORGAN'S CANOE AND OUTDOOR ADVENTURES - RELEASE OF LIABILITY In consideration of being allowed to participate in anyway in the MORGAN'S CANOE AND OUTDOOR CENTERS, INC program, its related events and

2 MORGAN'S CANOE AND OUTDOOR ADVENTURES - RELEASE OF LIABILITY In consideration of being allowed to participate in anyway in the MORGAN'S CANOE AND OUTDOOR CENTERS, INC program, its related events and activities, I, X, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or other, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated customary terms and conditions of participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from the participation and bring such to the attention of the Company immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE MORGAN'S CANOE AND OUTDOOR CENTERS, INC., their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ( Releasees ), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUPMTION OR RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTATIAL RIGHTS BY SIGNING IT AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. X Age: Date signed: PARTICIPANTS SIGNATURE FOR PARENTS/GUARDIANS OF PARTICIPANTS OF MINORITY AGE (UNDER 18 AT TIME OF REGISTRATION) This is to certify that I, as parent/guardian with legal responsi- bility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my child and our heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLI- GENCE OF THE RELEASEES, to the fullest extent permitted by law. X PARENT/GUARDIAN SIGNATURE, (also, print name) Date signed:

3 Rafting-Clinton County 4-H Camp Trip 2019 Waiver and Permission to Transport Child/Charge Ohio State University Extension Child/Charge: Event: Morgan s rafting trip transportation by Morgan s Location: 5701 State Route 350, Oregonia, Ohio (Morgan s Outdoor Adventures) Driver: Driver & bus provided by Morgan s Canoe Company. Date of Event: June 6, 2019 (Approximate trip time: 12:30-4:30 p.m.) Rain date: No rain date Trip: Camp Graham to Morgan s and return to Camp Graham. I give permission for my child to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I understand that participation in the identified event is not a requirement for participation in the county or state Extension programs. I have read, understand, and discussed with my child that: (1) They will be traveling in a motor vehicle driven by an adult and they are to wear their safetybelt while traveling; (2) They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip; (3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and (4) They are to remain in their seats and not be disruptive to the driver of the vehicle. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge The Ohio State University, its Board of Trustees, The Ohio State University Extension and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. Parent/Guardian Name (please print): Parent/Guardian Signature: Date: updated 4/2019

4 Royal Z Lanes-Clinton County 4-H Camp Trip 2019 Waiver and Permission to Transport Child/Charge Ohio State University Extension Child/Charge: Event: Royal Z Lanes Bowling Trip transportation by Clinton Massie School System Location: 2667 US-22, Wilmington, OH Driver: Driver & bus provided by Clinton Massie School System. Date of Event: June 5, 2019 (Approximate trip time: 12:30-4:30 p.m.) Rain date: No rain date Trip: Camp Graham to Adventure Cove and return to Camp Graham. I give permission for my child/charge ( child ) to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I understand that participation in the identified event is not a requirement for participation in the county or state Extension programs. I have read, understand, and discussed with my child that: (1) They will be traveling in a motor vehicle driven by an adult and they are to wear their safety-belt while traveling; (2) They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip; (3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and (4) They are to remain in their seats and not be disruptive to the driver of the vehicle. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge The Ohio State University, its Board of Trustees, The Ohio State University Extension and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. Parent/Guardian Name (please print): Parent/Guardian Signature: Date: updated 4/2019

5 Ziplining Trip to Camp Ozone-Clinton County 4-H Camp Trip 2019 Waiver and Permission to Transport Child/Charge Ohio State University Extension Child/Charge: Event: Trip transportation by Clinton Massie School System Location: Ozone Zipline Adventures at YMCA Camp Kern, 5291 OH-350, Oregonia, OH Driver: Driver & bus provided by Clinton Massie School System. Date of Event: June 4, 2019 (Approximate trip time: 12:30-4:30 p.m.) Rain date: No rain date Trip: Camp Graham to Ozone Zipline Adventures and return to Camp Graham. I give permission for my child to be transported in a motor vehicle driven by the individual identified to an event at the specified location on the date indicated. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or other adult volunteers. I understand that participation in the identified event is not a requirement for participation in the county or state Extension programs. I have read, understand, and discussed with my child that: (1) They will be traveling in a motor vehicle driven by an adult and they are to wear their safety-belt while traveling; (2) They are expected to respect each other, the vehicles they ride in, and the people they travel with during the trip; (3) Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers, or objects; and (4) They are to remain in their seats and not be disruptive to the driver of the vehicle. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses. As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge The Ohio State University, its Board of Trustees, The Ohio State University Extension and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child s behalf with regard to any damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms. Parent/Guardian Name (please print): Parent/Guardian Signature: Date: updated 4/2019

CITY KIDS DAY CAMP REGISTRATION FORM

RETURN CAMP ENTRY FORM WITH PAYMENT TO: M.C. PARKS 100 E. MICHIGAN BLVD. SUITE 2 MICHIGAN CITY, IN 46360 (219) 873-1506 www.michigancityparks.com CITY KIDS DAY CAMP REGISTRATION FORM 1. HOUSEHOLD INFORMATION