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Summer Camp Participant Information Form 2025

This Agreement and the provisions contained herein shall be construed, interpreted and controlled according to the laws of Ohio.

Release of All Claims and Agreement Not to Sue

As additional consideration of my application and permitting me the opportunity to participate in recreational activities and to utilize the facilities at the Mason Community Center and Mason Municipal Aquatic Center, the undersigned hereby waives, releases, discharges, saves, holds harmless, and indemnifies the City of Mason and the Mason City School District, their employees, volunteers, agents, and independent contractors, from any and all claims of whatever kind, to me, my spouse, or my dependents which may directly or indirectly arise. I hereby agree to accept any and all risk of personal injury, illness (including but not limited to COVID-19-related illness), death, or property damage and verify this statement by placing my signature below. Furthermore, by signing below for myself, my dependents, and/or my spouse, I understand this release bars claims by the undersigned’s spouse, dependents, heirs, assigns, executors, and administrators.

I understand that photographs and/or videotapes of me and my family members may be taken for use in promoting the City of Mason activities and facilities in future editions of CenterPoint, in a variety of other publications, on display boards throughout City facilities and for other uses by the City of Mason. I hereby give my permission to use such photographs without compensation to me.

Acknowledgment of Risk and Agreement to Participate: The sport of indoor rock climbing, bouldering wall, and inflatable Wibit presents inherent dangers and risks, both anticipated and unanticipated, including all manner of injury (both physical and emotional), paralysis, death, damage to property or to other participants, or other losses.

Physical injuries may include but are not limited to: cuts, abrasions or bruising; musculoskeletal injury; head injuries; and the like.

Physical injury may result from any activity involving participation with the indoor rock climbing facility, including but not limited to: contact or entanglement with climbing ropes or cables; falling and impacting the rock climbing wall, protruding holds, the floor or other surfaces and fixtures, both permanent and temporary; the jolt of the climbing rope when it catches a falling climber; falling climbers, ropes or other objects; overexertion or participation in activities beyond individual skill level, physical or mental capability; failure of equipment, including ropes, belay devices, harnesses, artificial holds, anchor points, climbing hardware, cables, or any other element of the climbing structure or any climbing equipment; any activity in or near the climbing area, including climbing, belaying, lowering on the rope, or any other climbing or ropes course activity; any neglect to follow established safety policies and procedures by any climber, belayer, spotter, spectator or any other person in or near the climbing area.

Participation in the sport of indoor rock climbing does not prepare participants for the sport of outdoor rock climbing. Further education, experience, and training are necessary to prepare participants for the inherent dangers and risks associated with outdoor rock climbing, which differ from those associated with indoor climbing.

Bouldering Wall Waiver: I acknowledge that the bouldering wall uses no personal protective equipment and that physical injury may result from participation in any activity using the bouldering wall including but not limited to: falling and impacting the bouldering wall, protruding holds, the floor or other surfaces and fixtures, both permanent and temporary; overexertion or participation in activities beyond individual skill level, physical, or mental capability; failure of equipment; any activity in or near the climbing area; any neglect to follow the established safety policies and procedures by any other climber, spotter, spectator, or any other person near the climbing area.

Physical injury may result from any activity involving participation with the inflatable Wibit, including but not limited to: falling off and entering the water unexpectedly. Participation must pass the competency test.


PLEASE PRINT

IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Wavier of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Agreement for full, adequate and complete consideration fully intending to be bound by same.

August 14, 2025

Please select who will be participating...
Minor
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First Campers Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Campers Date of Birth*
Date of Birth
First Campers Signature*
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Camper Information
Does participant need assistance to participate*
No
Yes

If Yes, please explain
Does participant need to take medication during program hours*
No
Yes
Participants Medications: (Any medication administration will follow our medication procedures at camp. This includes submitting a Medication Administration Form, available upon completion of camp waiver)

Please describe any other medical conditions you feel we should be aware of (Asthma, allergies, dietary restrictions, etc) *

Our Goal is to provide the best camp experience for each and every camper. Please provide any additional information that will help our camp team ensure your child has a successful summer camp experience.

My child may be picked up by the following people (Provide First and Last Name, Phone number, and relationship to the child) *
Camp Releases
AUTHORIZATION FOR EMERGENCY MEDICAL CARE: In case of an accident or illness, if I cannot be reached to make necessary arrangements, I AUTHORIZE or DO NOT AUTHORIZE the City of Mason to transport my child to the nearest hospital for emergency medical treatment*
Authorize
Do Not Authorize
MEDICAL HISTORY: I understand that participation in this activity is NOT recommended for persons who have any allergies or medical conditions or problems such as heart condition, seizures, high blood pressure, stomach problems, joint problems, hearing difficulty, breathing condition, diabetes, back problems, vision problems, migraines, dizziness, poor circulation, arthritis, toothaches, past surgery, or any other medical condition or difficulty that would prevent me from safely participating in this event. If I or the participant named above has any of these or other conditions or problems and still chooses to participate in this activity, I assume all risks associated with such participation.*
I HAVE READ AND UNDERSTAND THE ABOVE MEDICAL HISTORY STATEMENT
I do not understand the Medical History Statement Above
SUNBLOCK APPLICATION POLICY: Camp personnel are NOT responsible for the application of sunscreen to children. Parents are encouraged to apply sunscreen to their children before they arrive at camp and/or send sunscreen for their child to self-apply. We recommend packing spray-on sunscreen in your camper's backpack for easy reapplication during the day, along with a brimmed hat, sunglasses, T-shirt that fully covers back and shoulders, and a UV protection swim shirt for swimming days.*
I HAVE READ AND UNDERSTAND the Sunblock Application Policy
I DO NOT UNDERSTAND the above statement
MEDICAL CHECKUPS & IMMUNIZATIONS: My child is up to date on all necessary shots and medical Checkups.*
No
Yes
SWIMMING RELEASE: I Hereby CONSENT or DO NOT CONSENT for my child to attend all swimming sessions at any City of Mason Pool*
DO NOT CONSENT
CONSENT
TRANSPORTATION/FIELD TRIP RELEASE: I hereby CONSENT or DO NOT CONSENT for my child to be transported by the City of Mason to the Mason Municipal Aquatic Center, The Mason Community Center, and to and from various field trips. In the case of inclement weather, campers will be taken to the shelters at the park or to the Mason Community Center.*
DO NOT CONSENT
CONSENT
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Select Gender
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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