Spring Break Registration Form 2022Please enable JavaScript in your browser to complete this form. - Step 1 of 4How many children are you registering? (siblings only, please) *One child.Two children.Three children.Four children.If you change your mind, please update this selection to reflect the correct pricing.Select the full program or specific session(s):Monday - Thursday | April 4th-April 7th | 9:30am - 2:30pm | Ages 6-12 - $ 475 per child (5% discount for siblings)Register my Camp SHINEr for all four days:April 4th-April 7th - $ 475.00Register my Camp SHINErs for all four days: (two children)April 4th-April 7th - $ 902.50Reflects 5% sibling discount | $451.25 per childRegister my Camp SHINErs for all four days: (three children)April 4th-April 7th - $ 1,353.75Reflects 5% sibling discount | $451.25 per childRegister my Camp SHINErs for all four days: (four children)April 4th-April 7th - $ 1,805.00Reflects 5% sibling discount | $451.25 per childORSelect individual days (be sure to unselect above if not registering for the full program). *Thursday session is filled. Choose specific days:Monday - Leatherwork/Medicine Pouches + Nature Hike - $ 125.00Tuesday - Fairy/Gnome House Building - $ 125.00Wednesday - Felt Exploration - $ 125.00Choose specific days: (two children)Monday - Leatherwork/Medicine Pouches + Nature Hike - $ 237.50Tuesday - Fairy/Gnome House Building - $ 237.50Wednesday - Felt Exploration - $ 237.50Reflects 5% sibling discount | $118.75 per childChoose specific days: (three children)Monday - Leatherwork/Medicine Pouches + Nature Hike - $ 356.25Tuesday - Fairy/Gnome House Building - $ 356.25Wednesday - Felt Exploration - $ 356.25Reflects 5% sibling discount | $118.75 per childChoose specific days: (four children)Monday - Leatherwork/Medicine Pouches + Nature Hike - $ 475.00Tuesday - Fairy/Gnome House Building - $ 475.00Wednesday - Felt Exploration - $ 475.00Reflects 5% sibling discount | $118.75 per childCamper InformationPlease enter your child or children's information below.Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current School Grade *Select oneKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeName of second child *FirstLastDate of Birth (second child) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current School Grade (second child) *Select oneKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeName of third child *FirstLastDate of Birth (third child) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current School Grade (third child) *Select oneKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeName of fourth child *FirstLastDate of Birth (fourth child) *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current School Grade (fourth child) *Select oneKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeNextSave and Resume LaterParent/Guardian InformationName *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you interested in sponsoring a child to come to CAMP SHINE? *Yes, I'd love to. No thanks.I am unable right now but please send me more information.PreviousNextSave and Resume LaterCamp SHINE WaiverThe participant(s) listed above has/have my (our) permission to participate in CAMP SHINE I (We) as parent (s) or guardian (s) of the minor, do hereby, for my (our)______________________, myself, my (our heirs),executors & administrators, remise, release & forever discharge CAMP SHINE (Stephanie Telfer + Telfer family/property), employees, and volunteers from any & all liability, claims, or demands for any damage, loss or injury to the participant or personal property. I hereby certify that to the best of my (our) knowledge and belief said minor(s) are/ is in good health. In case of illness or accident, permission is granted for emergency treatment to be administered. It is further understood and agreed the the undersigned will assume full responsibility for any such action including payment of costs. I (we) do hereby advise that the above-named minor(s) have/ has the following allergies, medicine reactions or medical & physical condition which should be made known to a treating physician. I agree to not send my child/children to camp if sick or having any symptoms of illness.Do any of your registrants have any allergies, chronic illness, or medical conditions? *YesNo If yes, please describe. If no, please write "none". *Please be as specific as possible and include child's name if you are registering more than one child.Tell us about your child/children in more depth? What are their hobbies or talents? *Please include child's name if you are registering more than one child.Are there areas of concern or special needs we should know about so that that we can better support your child/children? How can we help them to SHINE? *Please include child's name if you are registering more than one child.Emergency Contact Information (Parent/Guardian)Name (Contact 1) *FirstLastIs address the same as the address entered earlier in this form? *YesNoAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Text? *YesNoEmail *Name (Contact 2) *FirstLastIs address the same as above? *YesNoAddress (Contact 2)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Contact 2) *Text? (Contact 2) *YesNoEmail (Contact 2) *Photo ReleasePlease select one. *Yes! You can use photos of my child/children to share with others about the SHINE Program!No! Please do not use photos of my child/children for marketing purposes.Signature | I_(parent/guardian) Give Permission for The SHINE Program to use photos of my child(ren) for the purpose of marketing and spreading the good news about the SHINE Program. *Clear Signature “A picture is worth a thousand words!” -UnknownNextSave and Resume LaterI have read and agree to the Camp SHINE Liability Form Below *YesPLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT, YOU ARE RELEASING CAMP SHINE + TELFER FAMILY + PROPERTIES FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORE ASSUMPTION OF RISK I, in my legal capacity as parent/guardian of the minor(s) named below__________________________ (“Minor(s)" filled in prior entry fields in form - for mulitple children this binds each child to this form”), acknowledge and agree that any use of CAMP SHINE + TELFER Family/Property PROGRAM facilities, property, services, equipment, and premises (“Facilities”) and any participation in THE SHINE PROGRAM and activities (“Programs”) come with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in the SHINE Program. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. Waiver, Release, Indemnification & Covenant Not to Sue In consideration of Minor’s use of Telfer Facilities, property, and participation in CAMP SHINE Program, I __________________________________________________ ("parent/guardian name" as filled in on prior page of this form) in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that CAMP SHINE + TELFER FAMILY/PROPERTY directors, agents, employees, volunteers, insurers, and representatives (“Releasees”) will NOT be liable for any personal injury, property damage, disability, death, sickness, or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage. Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as the parent/guardian of Minor, _______________________on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE WAIVE AND COVENANT NOT TO SUE. Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease, or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. I__________________________________ understand the inherent danger and unpredictable nature of animals and release the CAMP SHINE/TELFER FAMILY and all those associated from any incident of harm, damages, costs of any nature, including injury of all kinds to the participant/minor. I__________________________________ understand the inherent danger in swimming and being near a body of water/pool. With this knowledge, I release the CAMP SHINE/TELFER FAMILY and all those associated from any incident of harm, damages, costs of any nature, including injury of all kinds to the participant/minor. I____________________________________ understand that that due to our current circumstance with Covid-19 that there is risk regarding your child being around other people. Should your child contract Covid-19. I release the CAMP SHINE/TELFER FAMILY and all those associated from any incident of harm, damages, costs of any nature, including injury of all kinds to the participant/minor. In further consideration of the use of Telfer Facilities/property and participation in the CAMP SHINE Program, I, ______________________________________in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS. Releasees from any and all causes of action, claims, demands, losses, suits, liabilities, or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Telfer Facilities/property and participation in Programs.Download a copy of the Liability form for your records (PDF)Parent / Guardian Signature *Clear SignatureI have read and agree to the camp SHINE Liability form above for all children I have named on this form.Thanks for your time with this form! We can't wait to see your child at Camp SHINE Spring Break!We just need your payment and your child or children will be ready to join us. Registration total:$ 0.00Stripe Credit Card *CardName on CardPreviousSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternately, you can copy and save the link below. Please note, this link should not be shared and will expire in 24 hours, afterwards your form entry will be deleted. Copy Link Email * Send Link