Support NHS

*1.

Question - Required - I have read, fully understand, and voluntary sign this Parent/Guardian Waiver and Release of Liability form.

2.

Please provide the Parent/Guardian name, address, phone number and email below. This is for emergency contact purposes. (You will be asked to enter your child's information below.)

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

*

Phone Number: Required

Yes, I would like to receive e-mail from Nebraska Humane Society

Yes, I would like to receive postal mail from Nebraska Humane Society

Keep me logged in. What's this?

*3.

Question - Required - Child's First Name

*4.

Question - Required - Child's Last Name:

5.

Question - Not Required - Child's Nickname

*6.

Question - Required - Child's Age:

*7.

Question - Required - Child's Date of Birth:

Month

Day

Year

*8.

Question - Required - Please provide an emergency contact:

(Maximum response 255 chars, approx. 5 rows of text)

*9.

Question - Required - Please provide an emergency contact number:

*10.

Question - Required - T-Shirt Size

Child Small

Child Medium

Child Large

Adult Small

Adult Medium

Adult Large

Adult Extra Large

*11.

Question - Required - Parent/Guardian Digital Signature & Relationship to Minor:

*12.

Question - Required - Which Camp Kindness session(s) did you register your child for? Select all that apply.
Please make at least 1 selection from the choices below.

	Junior Session 1- June 3-7
	Junior Session 2- June 10-14
	Junior Session 3- June 17-21
	Junior Session 4- June 24-28
	Junior Session 5- July 8-12
	Junior Session 6- July 15-19
	Junior Session 7- July 22-26
	Senior Session 1- June 3-7
	Senior Session 2- June 10-14
	Senior Session 3- June 17-21
	Senior Session 4- June 24-28
	Senior Session 5- July 8-12
	Senior Session 6- July 15-19
	Senior Session 7- July 22-26

*13.

Question - Required - Person authorized to pick up your child's full name and phone number. If no one other than yourself is authorized to pick up, list N/A.

14.

Question - Not Required - Please list any allergies your child may have. Allergies that Camp Kindness staff need to be aware of include but are not limited to pets (dogs, cats, guinea pigs, horses, any animal), hay, and peanut butter. The Nebraska Humane Society is not liable for any allergies or information not provided in writing to Camp Kindness staff on this form.

*15.

Question - Required - Please list any medications or special needs your child may have during camp. Camp staff may call to discuss

*16.

Question - Required - From time to time the Nebraska Humane Society uses slides, or photographs of various educational activities. If you would be willing to allow us to use pictures of your child taken during NHS education programs as part of our public service or educational materials, please indicate by answering yes or no below.

*17.

Question - Required - How did you hear about Camp Kindness
Please make between 1 and 8 selections from the choices below.

	Facebook
	Instagram
	Twitter or Snapchat
	attended camp before
	friend/family
	NHS Employee
	Omaha World Herald Ad
	Westside School Summer Fun Guide
	NHS Website
	Event
	Flyer
	Other

*18.

Question - Required - I understand that camp staff reserves the right to contact parent/gaurdian to pick up youth due to behavioral concerns or safety of other campers. Refunds will not be provided in this case.

*19.

Question - Required - Waiver And Release of Liability (Form must be received prior to child being admitted to activities.) The undersigned is the parent/legal guardian of child(ren) named below. I understand that said child will be participating in activities at the Nebraska Humane Society and in the course of such activities said child may have direct contact with domestic animals. I further understand that the behavior of domestic animals is sometimes unpredictable and that some domestic animals are capable of inflicting serious personal injury, as well as extensive property damage. Knowing the risks of handling domestic animals, on behalf of the minor and myself, I agree to assume those risks and to release, indemnify, and hold harmless the Nebraska Humane Society and/or any of its Officers, Directors, Employees, Agents, or Contractors for any and all personal injury and property damages resulting from said child's participation in activities. PLEASE SIGN FIRST AND LAST NAME:

*20.

Question - Required - I also understand that said child is to remain on the Nebraska Humane Society property for the duration of the activities. If my child leaves the property during participation, with or without permission from a staff member, I release, indemnify, and hold harmless the Nebraska Humane Society for any and all personal injury and property damages resulting from said child leaving the Nebraska Humane Society property. I also hereby give the Nebraska Humane Society authority to seek emergency medical treatment for said child. I further attest that I know of no medical or other condition that would prevent said child from participation in activities at the Nebraska Humane Society. PLEASE SIGN FIRST AND LAST NAME:

*21.

Question - Required - I grant the right to photograph, reproduce, and use said child's artwork, written work, picture, silhouette, and other reproductions of physical likeness in connection with the Nebraska Humane Society promotions.

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