test2 - Gibson Island

This form should be completed by the camper's parent/guardian.
Please submit one form per camper.

* = Required Field (You will be unable to submit this form if any *Required* Fields are blank)

Camper Information

Camper Name *

Camper Relation to Sponsoring Member: *

Child

Grandchild

Niece/Nephew

GUEST

Other

Sponsoring GIC Member & Member # *

Age *

Grade entering, Fall 2024 *

Birth Date *

Camper Type *

New

Returning

Camper's Parent/Guardian Info

Parent/Guardian Name *

Contact #: *

Email *

Gibson Island Club Program Release and Waiver of Liability, Assumption of Risk, and Indemnity and Parental Consent Agreement

By signing below, I hereby approve my child's participation in the Summer Camp, Junior Fleet and/or Academy (collectively "Programs"), including without limitation the Club’s Summer Camp Tuesday Evening Off-Island Activities on (July 9, July 16 and July 23, and any other activities which may be scheduled), all as provided by the Gibson Island Club, Inc. (“Club"). I hereby acknowledge that the participation in the Club’s Programs is a benefit offered to me as part of my Club membership. In consideration of this service, I, individually and on behalf of my child knowingly waive, release, discharge, and agree not to sue the Club and/or the Gibson Island Corporation (“Corporation”), their officers, governors, directors, employees, members, committee members, shareholders, and Program instructors on any claim, cause of action, injury, or damage that my child or I may have that arises out of my child's participation in any Program, and I agree to indemnify and hold harmless the Club and the Corporation from any such claim. I understand that there are certain risks of injury inherent in the Programs’ activities in which my child will participate, and I hereby assume those risks and any claims or damages therefrom, on the account of injury to my child's person or property on behalf of my child, my child's personal representatives, heirs and assigns. I further understand that neither the Club nor the Gibson Island Corporation (“Corporation”) assume any liability for injury or damages which arise or result from my child's participation in the Programs. I certify that my child is healthy and has no physical, mental, or other conditions that restrict my child's full participation in the Program(s), other than those listed on the Consent to Treatment, Emergency Contact & Health History Form. I also understand and agree to assume liability and responsibility for any damage done to the Club's or Corporation’s property or property of others by my child or my guest. I also agree that should my child be disruptive in any of the Programs, an attempt will be made to contact me and then arrangements will be made for my child to be sent home or to a caregiver of my choice. I further agree that if my child is dismissed from any of the Programs because of disruptive behavior, I am not entitled to any refund. I hereby grant the Gibson Island Club permission to use my child’s name, picture, or like in any form of media, print or otherwise that is distributed only to members of the Gibson Island Club and Shareholders.

Signature (Parent or Legal Guardian) *

Camper Health Insurance Information

Name of Insured *

Relation to Child *

Insurance Provider *

Policy # *

Preferred Hospital in emergency *

Emergency Contact Information

Please list two people (other than parents) who may be contacted in case of emergency.

Emergency Contact #1 *

Relationship *

Cell Phone *

Emergency Contact #2 *

Relationship *

Cell Phone *

Pick Up Permissions

The following people (other than parents) may pick up my child. Proper ID will be required.

Name

Contact #:

Name

Contact #:

I give my child permission to walk or ride their bike to and from Camp tent, tennis, golf and/or the Point.

Form Designer

2024 Summer Youth Programs Registration Form

Gibson Island Club, inc.

Gibson Island Corporation

410-255-1414