2025 Summer Camp Waiver and Authorizations Thank you for signing up for summer camp! We look forward to an exciting camp experience. Please ensure to complete this form by June 2, 2025. Step 1 of 7 14% Camper InformationCamper's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Parent/Guardian InformationParent/ Guardian Name(Required) First Last Relationship to Camper(Required)Email(Required) Phone(Required)Home Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Add another parent/guardian?(Required) Yes No Add additional emergency contact (other than parent/guardian)(Required) Yes No Additional Parent/Guardian InformationParent/ Guardian Name(Required) First Last Relationship to Camper(Required)Email(Required) Phone(Required) Emergency Contact InformationName(Required) First Last Phone(Required)Relationship to camper(Required) Allergy & Medical InformationDoes your camper have any allergies?(Required) Yes No Describe your camper's allergies and any care instructions(Required)Does your camper require any medication during camp?(Required) Yes No Provide medication details and instructions(Required)Does your child have any medical conditions we should be aware of?(Required) Yes No Please Explain(Required)Camper's primary physician(Required)Physician's Phone Number(Required)Physician Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Self-Release/Pick-up AuthorizationPhoto identification will be required before campers will be released. Do you prefer your camper to self-release or be released only to an authorized person?(Required) Self-Release Release to Authorized Pick-Up Person I allow my camper to self-release at the end of each day.(Required) Yes No Additional Authorized Pick-Up PersonParents and guardians will automatically be allowed to pick up. Please add any additional authorized persons.NamePhoneNamePhoneNamePhone California Historical Radio Society (CHRS) Children’s Camp Liability Waiver and Release of Claims 1. Acknowledgment of Risk I, the parent or legal guardian of the above-named child (“Participant”), understand and acknowledge that participation in the CHRS Camp involves activities that may expose the Participant to certain risks. These activities may include, but are not limited to: Hands-on interaction with vintage electronic equipment, tools, and radios Demonstrations and supervised activities involving electrical circuits and soldering Exposure to low-voltage power sources and old electrical components Use of hand tools, sharp objects, and mechanical parts Movement throughout a historic facility, which may include uneven surfaces, stairs, or outdoor areas Potential exposure to dust, mild chemicals (e.g., cleaning solvents), or other substances present in a workshop environment Participation in indoor and outdoor activities that may involve heat, sun exposure, or minor environmental hazards Acknowledgement(Required)I acknowledge and accept the inherent risks associated with these activities, which may include — but are not limited to — minor injuries (such as cuts, scrapes, bruises), sprains, allergic reactions, electrical shock, burns, exposure to fumes or cleaning agents, and in rare cases, more serious injury due to fire, electrocution, or contact with vintage or malfunctioning equipment. Yes No 2. Waiver and Release of Liability(Required)In consideration for CHRS permitting the Participant to attend and participate in the camp, I hereby release, waive, and discharge CHRS, its officers, directors, employees, volunteers, contractors, and agents from any and all liability, claims, demands, causes of action, damages, or losses, whether known or unknown, arising out of or related to the Participant’s attendance or participation in the camp, including but not limited to injury, illness, property damage, permanent disability, or death caused by risks described in this agreement or from any negligence on the part of CHRS or its representatives. Yes No 3. Medical Authorization and Emergency Care(Required)I authorize CHRS staff or volunteers to administer basic first aid and/or seek emergency medical care for the Participant if necessary. I understand that CHRS will attempt to contact me or an emergency contact before or immediately after such care is provided. I agree to be solely responsible for any and all medical expenses incurred as a result of any accident or injury. Yes No 4. Media Release(Required)I give permission for CHRS to photograph or record the Participant during camp activities and to use these images for promotional purposes in print or digital formats, including but not limited to websites, social media, and newsletters. Yes No 5. Behavior and Safety Expectations(Required)I understand that the Participant is expected to follow all instructions and safety guidelines provided by CHRS staff and volunteers. Any behavior deemed unsafe, disrespectful, or disruptive may result in the Participant being removed from the camp without refund. CHRS reserves the right to terminate participation in the event of violations of safety protocol, particularly those involving hazardous equipment or substances. Yes No 6. Assumption of Full Responsibility(Required)I acknowledge that I am voluntarily allowing the Participant to take part in activities that may involve inherent risks and dangers. I assume full responsibility for any risk of bodily injury, illness, death, or property damage resulting from the Participant’s involvement, whether caused by negligence or otherwise, and whether occurring on or off CHRS premises. Yes No 7. General Provisions(Required)This release is governed by the laws of the State of California. If any part of this agreement is deemed unenforceable, all other parts shall remain in full force and effect. I certify that I am the legal parent or guardian of the Participant, that I have read this waiver and understand its contents, and that I sign it voluntarily and knowingly. Yes No Signature Additional CommentsWhat other information would be useful for us to know about your camper?PhoneThis field is for validation purposes and should be left unchanged. Δ
