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Museum Camp Program Personal Data Form

  1. JCPRD logo

  2. Johnson County Museum Program Personal Data Form

    Please complete this form for each child enrolled in a drop-off museum experience. No child may be left in the care of museum staff without this form on file. Thank you for your cooperation!

  3. List all individuals (in addition to above) who are authorized to pick up your child. Please note that all individuals will be required to show Photo Identification at pick up.

  4. Does your child have any food/substance allergies? *

  5. Does your child have any medical conditions, special needs, or activity restrictions? *

  6. JCPRD WAIVER STATEMENT

    The undersigned states that he/she understands that the Johnson County Park & Recreation District is not and shall not be responsible for or liable for any illness, injury, or death to person or damage to property, including but not limited to illness, injury, or death arising from exposure to the Novel Coronavirus (COVID-19), resulting from the program in which the undersigned is enrolling or being enrolled or from his/her participating in said program, and the participant and the undersigned, if the participant is a minor or under other legal disability, hereby forever releases and holds harmless the said Johnson County Park & Recreation District, it's employees, agents and representatives from any and all claims of any kind, including but not limited to claims arising from exposure to the Novel Coronavirus (COVID-19), that the participant, or the undersigned or their respective heirs, executors, administrators, or assigns may have or claim to have resulting from participation in said program. NOTICE: By enrolling in this program you hereby acknowledge the Johnson County Park & Recreation District can and may photograph and/or video tape program participants and then use such images without payment or any other consideration, for purposes of publicizing District parks, facilities, programs or services, or for any other lawful purpose.

  7. CANCELLATION POLICY

    The fee for this program is non-refundable, unless cancelled by the museum, or if there is a child on the waitlist that can fill the spot. This includes illness of child and change of care plans for the day. No partial refunds will be given.

  8. I HAVE READ & UNDERSTAND THE WAIVER STATEMENT & CANCELLATION POLICIES:

  9. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  10. Leave This Blank:

  11. This field is not part of the form submission.