EnQuest Daycamp Program Participant Form This form must be completed by a parent or guardian before a registered student can participate in the camp. X/TwitterThis field is for validation purposes and should be left unchanged.CAMPER INFORMATIONParticipant First Name(Required)Participant Last Name(Required)Participant DOB(Required) MM slash DD slash YYYY Age on July 13(Required)Participant Phone(Required)Participant Email(Required) Participant Gender(Required)Participant Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CUSTODIAL PARENT/GUARDIAN INFORMATIONParent/Guardian Name(s)(Required)Parent/Guardian Cell Phone(Required)Parent/Guardian Home or Work PhoneEMERGENCY CONTACTEmergency Contact Name(Required)Relationship to camper(Required)Emergency Contact Primary Phone(Required)Emergency Contact Alternate PhonePERMISSIONSPLEASE READ THE FOLLOWING PARAGRAPHS CAREFULLY. IF YOU HAVE ANY QUESTIONS REGARDING THIS AGREEMENT OR WOULD LIKE TO NEGOTIATE ITS TERMS, CONTACT Chris Beimborn at (414)251-9140.Terms and Conditions(Required)The EnQuest Day Camp will involve the use of power tools and hand tools including drills and soldering irons. Participants will create sand molds in the UW-Milwaukee Foundry & Materials Processing lab and observe metal casting in this facility. Participants may also go on field trips to locations at UW-Milwaukee and off campus with provided transportation and participation in the camp requires these activities. I, the undersigned parent or guardian, give permission for my child/ward named above to participate in the University of Wisconsin-Milwaukee (UWM) sponsored activity identified above, and in doing so, voluntarily agree to assume all of the risk and responsibilities involved in my child/ward’s participation in this activity. ASSUMPTION OF RISKS You are being asked to sign this form because you would like to participate in the above-listed event (the “Program”) sponsored by the University of Wisconsin-Milwaukee (“UWM”). Before you can participate, UWM asks that you read this document carefully. If you want to ask questions about this document or request changes to it, you can do so by contacting the party listed above. I understand that the UW-Milwaukee EnQuest Day Camp, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries and/or illness. I am aware of the risks of participation, which include, but are not limited to minor injury such as bruises, contusions, broken bones, concussion, and catastrophic injuries, such as paralysis and even death. UWM recommends you minimize your risks by talking to a doctor before participating in the Program. I know, understand, and appreciate the risks that are inherent in the above-listed activity. I hereby assert that participation is voluntary and that I knowingly assume all such risks. I confirm that I have read and understood the terms outlined above.Camper Name(Required)Parent/Guardian Signature(Required)Retype name to signDate(Required) Month Day Year HOLD HARMLESS, INDEMNITY AND RELEASE(Required)In consideration of my child/ward’s participation in these activities, I , for myself, spouse, heirs, personal representatives, estate or assigns, agree to defend, hold harmless, indemnify and release the Releasees and their officers, employees, agents, and volunteers from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, personal injury, or death which may result from participation in the above-listed activity. This release includes claims based on the negligence of the Releasees, and their officers, employees, agents, and volunteers, but expressly does not include claims based on their intentional misconduct or recklessness. I understand that by agreeing to this clause, I am releasing claims and giving up substantial rights, including my right to sue. I confirm that I have read and understood the terms outlined above.Camper Name(Required)Parent/Guardian Signature(Required)Retype name to signDate(Required) Month Day Year RELEASE FOR USE OF PHOTOS AND LIKENESS BY UWM (OPTIONAL)I understand that the University of Wisconsin-Milwaukee (“UWM”) and partners of the UWM EnQuest Day Camp may take photographs, video, audiotape and other image and sound-based media of the campus, (including inside its buildings and including through the use of drones), and its employees, students, and visitors (collectively, the “Images”). UWM may wish to use such Images for educational, promotional, advertising, and other purposes, including, but not limited to printed publications and on its website. Therefore, I hereby freely and voluntarily consent to the use and publication of my name, participation, picture, and/or likeness by UWM and/or its employees and/or agents for any and all purposes including, but not limited to, educational, promotional, advertising, and trade, through any medium or format as technology may now or in the future allow, including, but not limited to, videotape, audiotape, webcasting, podcasting, film, photograph, television, radio, digital, internet, theater, or exhibition, at any time from this date forward. I further waive any claims against UWM and/or its employees and/or agents based upon or related to its use or publication of my likeness, voice, participation, and/or picture. I understand that this form is optional, and I am not required to sign it. I freely give this authorization without expectation of compensation. I confirm that I have read and understood the terms outlined above.Camper NameParent/Guardian SignatureRetype name to signDate Month Day Year Parent/Guardian Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code RELEASE FOR UNSUPERVISED ARRIVAL AND DEPARTUREI understand that in order for a minor participant in a UW-Milwaukee program to arrive and leave unattended, consent of a parent or guardian must be given. This is required for participants who may travel to and from UWM independently or with another minor, or who may wait independently after being dropped off early or picked up late. This authorization does not allow the participant to leave during the program without prior notification and arrangements. Consent to unattended arrival/departure may be revoked by UW-Milwaukee in the case of unsuitable behaviors on the part of the participant. Should consent be revoked, the participant will be required to have a parent/guardian accompany him/her upon arrival and departure. This form is not necessary for students who will arrive and depart accompanied by a parent or guardian at the program start and end times. I understand that at the conclusion of each day of camp, UW-Milwaukee will no longer have custodial responsibility for my child/ward, and I give authorization for the child to arrive and depart unattended. I confirm that I have read and understood the terms outlined above.Camper NameParent/Guardian SignatureRetype name to signDate Month Day Year CAMPER HEALTH INFORMATIONCheck all that apply:(Required)(Depression, Anxiety, ADHD, ADD, etc…) Asthma Diabetes Epilepsy/Seizures Headaches Mental Health Conditions Cognitive/Developmental Concerns Dizziness, light-headedness, or fainting associated with exercise in the past year Unexplained, rapid or irregular heartbeat within the last year A physician has denied or restricted participation in sports due to a heart problem None of the above Please indicate camper allergies here:(Required)Check all that apply. Medications Seasonal allergies Insect stings Foods Other Do allergies require EPI PEN injection? No known allergies Please name specified allergens here.Does the camper use an inhaler?(Required) Yes No Date of last Tetanus booster (Td or Dtap or DTP):Note: a tetanus shot is not required for camp attendance. However, it is important for medical professionals to know if you have or have not had a current tetanus booster in case of emergency. MM slash DD slash YYYY Describe any limitations or restrictions of program activities:Describe any special accommodations regarding physical or emotional conditions we need to be aware of regarding your participation in this program: