Critter Camp Registration Form

Critter Camp hours: 9 am- 3 pm          

Summer Break  Critter Camp

Intended for Age Groups

June 4-June 8

June 18 –June 22

July 9-13

July 23-27

7-12 years old

Child’s Name: ____________________________________ Age: _________  School:  _____________________

Date of Birth: ___________   Boy ___ Girl ____ Parents/Legal Guardian: ________________________________

Special Needs, dietary needs: ________________________________________

Address: _________________________________________________________

Work or Cellular Phone: _______________ Home Phone: _________________

E-mail address: ____________________________________________________

Payment is due prior to start of camp.

If you would like early drop off or late pick-up, the fees are $ 10.00/a day for 8 am drop off or for 4 pm late pick-up.

Total Enclosed: _________________Please make your check payable to Kauai Humane Society. You may pay by Visa or MasterCard by calling 632-0610 ext. 103 or by filling out the credit card information below.

Credit Card Number_______________________ Expiration Date: ________                                                                  

Cardholder’s Signature: _____________________Security code: ____ Date: __________.

Kauai Humane Society P.O. Box 3330 Lihue HI 96766.

Contact – Esther@kauaihumane.org

Mahalo for your support

Kauai Humane Society Critter Camp Waiver and Release of Liability

I, _________________________, the Parent/Legal Guardian of __________________, understand the nature of the activities that my child will be participating in on the date(s) _______________________ at the Kauai Humane Society Critter Camp.  I also understand the nature of domestic shelter animals and that their behavior is sometimes unpredictable which can give rise to risks such as personal injury or infection.  Knowing this, I, and anyone who might claim on my behalf, release the Kauai Humane Society, Officers, Directors, Staff, Volunteers and all others affiliated with the Kauai Humane Society from any and all claims and liability of any kind arising out of personal injury and property damage of any kind resulting from my child’s participation in activities during Critter Camp.

In the event that my child requires medical attention, I authorize the Kauai Humane Society to seek proper medical help at my expense. Initial ____

I am also aware that allergies exist.  I have listed below all of my child’s known allergies, all of my child’s physical limitations and any special needs that my child might have.  In addition, I have no knowledge of any medical condition that would prevent my child from participating in the activities at Critter Camp.

Any known allergies (i.e. cats, nuts, etc.):   ____________________________________________________________

Any physical limitations or other needs; including dietary ____________________________________________________________

Physician’s name, phone number and address: ____________________________________________________________

Emergency contact name and phone number: (please list two):

Name: __________________________   Number: _____________________   

Name: __________________________   Number: _____________________   

Parent/legal guardian name: _____________________________________________________________

Address:  _____________________________________________________

Other individuals authorized to pick up my child are:  _____________________________________________________________ (Relation)

_____________________________________________________________ (Relation)

My signature:   _____________________________   

Date:            ____________________________

Dear Parents or Guardian:

During your child’s participation in Critter Camp, Kauai Humane Society staff may photograph your child for use in marketing and promotional materials for the Kauai Humane Society and its’ programs.  These photographs or videos of your child are the property of the Kauai Humane Society and may be used in any appropriate matter we may choose.

Your child will be participating in a special art project during Critter Camp; the artwork from this project will also become the property of the Kauai Humane Society. This includes, but is not limited to, the use in promoting future Critter Camps, newsletters or other forms of marketing.

Media Release for Minors Critter Camp

I, _____________________________________ being Parent/Guardian of ___________________________________ understand and agree that the Kauai Humane Society may use my child’s name, videos and photographs in which my child appears, and/or audio recording made of my child’s voice for publicity or promotional purposes for the Kauai Humane Society without any liability or obligation to me or my child.  All photographs and video/audio recordings are the property of the Kauai Humane Society.  I also understand that the special art project that my child will participate in at Critter Camp is also the property of the Kauai Humane Society.

Child’s Name:  ______________________________________________________

Parent/Guardian’s Name: _______________________________________________

                                                                            

Signature:  _______________________

Date:       ________________________

Critter Camp at the Kauai Humane Society

Critter Camp will be held at the Kauai Humane Society located at 3-825 Kaumualii Highway, in the classroom.

CRITTER CAMP HOURS:  9:00am – 3:00pm Monday through Friday.

Kauai Humane Society doors will open at 8:45 AM.

Please make sure your child has:

    • A sack lunch
    • A bottle of water
    • CLOSED TOED SHOES.  (Please–NO SLIPPERS, NO SANDALS OR HIGH HEELED SHOES.)
    • Sunscreen. Many activities will be outside.
    • Snacks will be provided for the campers.  You are welcome to send your child with their own snacks if you wish.  

Please remember:

    • For safety reasons, parents or guardians will be required to sign their child in and out of camp each day.
    • Please be prompt when dropping off your child at 9:00am and picking up your child at 3:00pm.  Early pick-up and late drop can be arranged for a fee.
    • It is necessary to inform the Critter Camp in writing if there are other individuals authorized to sign your child in or out of camp.
    • Please be sure to label your child’s belongings.

Cancellation Policy:

  There will be a $10.00 processing fee for any cancellation.