TOTAL FEE:
1-3 DAYS/WK 4-5 DAYS/WK
RES NR RES NR
Kindergarten Camp $99 $147 $149 $199
Explorers & Navigators $99 $147 $149 $199
On The Go Camp $105 $155 $165 $215
Before Camp $21 $32 $30 $45
After Camp $36 $54 $50 $75
Wrap Up Camp Aug 10-11 $50/day $75/day
Pottawatomie Camp
Weekly Fees
SELECT CAMP:
Please indicate camp dates with (X) to the right.Please indicate camp dates with (X) to the right.
Child’s Name ________________________________________________________________________ Birthdate _____ _____ / _____ _____ / _____ _____ Sex
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PHOTOS: I understand that my child/ward or I may be photographed or videotaped while participating in a St. Charles Park District program or event. I give permission for photos and video of my child/ward or me to be used to promote the
St. Charles Park District. Such photos/video will remain the property of the St. Charles Park District. Please call 630-513-6200 with any questions.
RESIDENCY RATE DISCLAIMER: Residency rates apply to anyone who lives within the St. Charles Park District boundaries. Final determination of residency will be made when processed by the Business Department, not at time of purchase.
Signature of Participant or Parent/Guardian Date
participation will be denied if the signature of adult participant or parent/guardian and date are not on this waiver.
St. Charles Park District Registration Form - Pottawatomie Camp
8 North Ave., St. Charles, IL 60174 • 630-513-6200 • Fax 630-513-9304 • eMail: registration@stcparks.org
Only one participant per form. Complete all information neatly and carefully. Must create an ePACT account to complete medical/emergency contact information.
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SINCE
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FOR OFFICE USE ONLY
Received By ___________________
Date _________________________
Kindergarten Camp Explorers Camp Navigators Camp On The Go Camp Before Camp After Camp Wrap Up Camp
Entering Kindergarten Entering Grades 1-2 Entering Grades 3-4 Entering Grades 5-6 Entering Grades K-6 Entering Grades K-6 Entering Grades K-6
Monday Tuesday Wednesday Thursday Friday
Week 1 May 25 (no camp) May 26 May 27 May 28 May 29
Week 2 June 1 June 2 June 3 June 4 June 5
Week 3 June 8 June 9 June 10 June 11 June 12
Week 4 June 15 June 16 June 17 June 18 June 19
Week 5 June 22 June 23 June 24 June 25 June 26
Week 6 June 29 June 30 July 1 July 2 July 3
Week 7 July 6 July 7 July 8 July 9 July 10
Week 8 July 13 July 14 July 15 July 16 July 17
Week 9 July 20 July 21 July 22 July 23 July 24
Week 10 July 27 July 28 July 29 July 30 July 31
Week 11 August 3 August 4 August 5 August 6 August 7
Week 12
(Wrap Up) August 10 August 11
School resumes August 12.School resumes August 12.
Check # (check one) Cardholder Name Charge Amount
Card # _ _ _ _ - _ _ _ _ - _ _ _ _ - _ _ _ _ Exp. Date _ _ / _ _ CV V# Signature
NOTE: Credit card payment is required for FAX and eMail registrations. It is mutually understood that the FAX or eMail registration document (including the Waiver & Release of all Claims) shall substitute for and have the same legal
effect as the original form.
Main Contact - Last Name _____________________________________________ First Name ________________________________________________ Date ___________________
Address __________________________________________________________________ City __________________________________ State ___________ Zip _________________
Primary Phone __ __ __ - __ __ __ - __ __ __ __ Secondary Phone __ __ __ - __ __ __ - __ __ __ __ E-mail _____________________________________________________________
Please list any physical or other limitations, allergies, special medication or additional conditions that may affect program/activity participation. If special accommodations are needed, allow 2 weeks prior to the start of the program.
Waiver & Release of All Claims and Assumption of Risk
I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity and I voluntarily
agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may
sustain as a result of said participation. I further agree to waiver and relinquish all claims my minor child/ward or I may have or
accrue to my child/ward or me as a result of participating in this program/activity against the St. Charles Park District, including
its officials, agents, volunteers and employees. I do hereby fully release and forever discharge the St. Charles Park District from
any and all claims for injuries, damages, or loss that my minor child/ward or I may have or which may accrue to my minor
child/ward or me and arising out of, connected with, or in any way associated with this program/activity.
Liability Waiver Form
You are solely responsible for determining if your minor child/ward or you are physically fit and/or skilled for the
activities contemplated by this agreement. It is always advisable, especially if the participant is pregnant, disabled in any
way or recently suffered an illness, injury or impairment, to consult a physician before undertaking any physical activity.
Please read this form carefully and be aware that in signing up and participating in this program/activity, you will be
expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which your
minor child/ward or you might sustain as a result of participating in any and all activities connected with and associated
with this program/activity including transportation services, when provided.
