2018 Safety Camp Registration

Please complete a single form for each child you are registering. Thank you.

Child's Name

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Child's Date of Birth

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Child is entering Grade 4?

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Child's T-Shirt Size

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Parent/Guardian Name

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Address

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Primary Contact Number

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Mobile Phone Number

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Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Signature of Parent/Guardian

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Emergency Contact Information:

Emergency Contact #1

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Emergency Contact #1 Phone Number

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Relationship

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Emergency Contact #2

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Emergency Contact #2 Phone Number

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Relationship

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***Other Medical information you feel may be necessary for the staff to know - please include any allergies

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Please list every individual that is allowed to pick up your child - including yourself. Those picking up your child will be required to sign your child out every day. Those not on the list will not be allowed to pick up your child without previous permission.

Those authorized to pick to your child up:

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Questions??? Contact Battalion Chief Maydak @ 414-357-0113 x1512 or jmaydak@nsfire.org.

T-shirts will only be ordered for participants registered before June 22

Safety Camp Release of Liability and Consent to Participate

I/We consent to our child/children (the “Participant” listed on the Safety Camp registration form attached) participating in the North Shore Fire Rescue Safety Camp (“Safety Camp”). I/We agree that our child’s participation in the Safety Camp is completely voluntary and is provided at a nominal charge to cover the expense of food, snacks, t- shirts and awards.

In consideration of the North Shore Fire Department’s (“NSFD”) allowing our child to participate in the Safety Camp I/We hereby agree to release, discharge, indemnify and hold harmless the NSFD and its member Municipalities, employees, officers, officials, agents, insurers and successors or assigns(the “released parties”) from any and all claims including those for, personal injuries, property damage, wrongful death, costs, expenses and attorney’s fees arising from or which may accrue as a result of from and for any loss, injury (including death) and/or damage of or to any person, including my child/children, or property resulting from or claimed to be a result of any conduct or act taken or omitted by or to my child/children while or as a result of his/her participation in the Camp, whether due in whole or in part to negligent acts or omissions of the NSFD, its, officers, agents, sponsors, officials, attorneys, volunteers, or employees. I understand and agree that the nature of the Safety Camp may involve a degree of risk from a variety of sources which could result in serious bodily injury to my child/children (including death) and/or damage to my child/children’s property, and that, being fully advised and aware of the same, I assume and accept full responsibility for any risk that may result from my child/children’s participation in the Safety Camp. The release and indemnity is not intended to apply for claims arising out of reckless or intentional acts.

By allowing my child/children to attend the camp I acknowledge and consent to the use of any photographic images of the Camp attendees, instructors and volunteers that may be captured during the Camp, and further understand that photographic images and video and audio recordings may be used as promotional materials by the NSFD.

If any part of this Release and Consent shall be held invalid or unenforceable under applicable law, then the remaining terms and provisions of this Agreement shall not be affected thereby; and each such remaining term and provision shall be valid and enforced to the fullest extent permitted by applicable law.

I/We have read this Release of Liability and Consent to Participate and my/our signature below is intended to be binding upon me/us and all my/our heirs, successors, and assigns.

Signature

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Today's Date

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Printed Name

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Relationship to camper:

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Payment

The tuition for Safety Camp is $50. Tution can be paid by cash, check or credit card (check preferred). Payment can be mailed to the North Shore Fire/Rescue Community Risk Reduction Bureau at:

North Shore Fire/Rescue St. 85

Attn: Community Risk Reduction

665 E. Brown Deer Rd.

Bayside, WI 53217

Credit Card Payments may be made in person or by phone at (414) 357-0113 ext. 1101. They can also be processed below.

Would you like to pay by credit card now?

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2018 Safety Camp Registration

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Child's Name

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Child's Date of Birth

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Child is entering Grade 4?

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Child's T-Shirt Size

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Parent/Guardian Name

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Address

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Primary Contact Number

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Mobile Phone Number

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Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Signature of Parent/Guardian

Emergency Contact Information:

Emergency Contact #1

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Emergency Contact #1 Phone Number

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Relationship

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Emergency Contact #2

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Emergency Contact #2 Phone Number

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Relationship

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***Other Medical information you feel may be necessary for the staff to know - please include any allergies

Those authorized to pick to your child up:

Questions??? Contact Battalion Chief Maydak @ 414-357-0113 x1512 or jmaydak@nsfire.org.

T-shirts will only be ordered for participants registered before June 22

Safety Camp Release of Liability and Consent to Participate

I/We have read this Release of Liability and Consent to Participate and my/our signature below is intended to be binding upon me/us and all my/our heirs, successors, and assigns.

Signature

Today's Date

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Printed Name

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Relationship to camper:

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Payment

The tuition for Safety Camp is $50. Tution can be paid by cash, check or credit card (check preferred). Payment can be mailed to the North Shore Fire/Rescue Community Risk Reduction Bureau at:

North Shore Fire/Rescue St. 85

Attn: Community Risk Reduction

665 E. Brown Deer Rd.

Bayside, WI 53217

Credit Card Payments may be made in person or by phone at (414) 357-0113 ext. 1101. They can also be processed below.

Would you like to pay by credit card now?

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2018 Safety Camp Registration

Please complete a single form for each child you are registering. Thank you.

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Child's Name

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Child's Date of Birth

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Child is entering Grade 4?

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Child's T-Shirt Size

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Parent/Guardian Name

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Address

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Primary Contact Number

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Mobile Phone Number

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Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Signature of Parent/Guardian

Emergency Contact Information:

Emergency Contact #1

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Emergency Contact #1 Phone Number

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Relationship

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Emergency Contact #2

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Emergency Contact #2 Phone Number

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Relationship

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***Other Medical information you feel may be necessary for the staff to know - please include any allergies

Those authorized to pick to your child up:

Questions??? Contact Battalion Chief Maydak @ 414-357-0113 x1512 or jmaydak@nsfire.org.

T-shirts will only be ordered for participants registered before June 22

Safety Camp Release of Liability and Consent to Participate

I/We have read this Release of Liability and Consent to Participate and my/our signature below is intended to be binding upon me/us and all my/our heirs, successors, and assigns.

Signature

Today's Date

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Printed Name

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Relationship to camper:

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Payment

The tuition for Safety Camp is $50. Tution can be paid by cash, check or credit card (check preferred). Payment can be mailed to the North Shore Fire/Rescue Community Risk Reduction Bureau at:

North Shore Fire/Rescue St. 85

Attn: Community Risk Reduction

665 E. Brown Deer Rd.

Bayside, WI 53217

Credit Card Payments may be made in person or by phone at (414) 357-0113 ext. 1101. They can also be processed below.

Would you like to pay by credit card now?

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2018 Safety Camp Registration

Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Emergency Contact Information:

Safety Camp Release of Liability and Consent to Participate

Payment

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2018 Safety Camp Registration

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Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Emergency Contact Information:

Safety Camp Release of Liability and Consent to Participate

Payment

2018 Safety Camp Registration

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{{ Cognito.resources['order-billing-info-header'] }}

Medical Release

In the event of an emergency, I hearby give North Shore Fire/Rescue or Glendale Police Department and their employees permission to seek medical attention for my child/dependent.

Emergency Contact Information:

Safety Camp Release of Liability and Consent to Participate

Payment