Camp Emergency Contact, Health Waiver and Release Form
Prior to filling out this form, please read the Essential Eligibility Criteria (EEC) document. The EEC and other camp forms may be downloaded from www.LCFPD.org/camps or requested by calling 847-968-3321. One form per child serves all camp sessions. The completed camp forms must be received to attend camp.
Our primary means of communication with you is through email.
Please list all camps your child is attending including the program name, session date, and location
Contacts for Emergencies and Camp Cancellations:
Persons listed must be reachable during camp hours. List contacts in priority order.
Emergency/Cancellation Contact 1:
Emergency/Cancellation Contact 2:
Emergency/Cancellation Contact 3:
Persons Authorized for Child Pick-Up (in addition to emergency contacts listed previously)
Camp staff will not release your child unless proper photo identification is shown daily by any person listed.
Medical Information and Special Considerations
Check any that apply to your child. With awareness of your child’s needs, activities and techniques will be assessed for modifications.
Any physical, emotional or behavioral conditions, including cognitive, LD, ADD, ADHD, or autism requiring medication, treatment, special restrictions or considerations while at camp?
List any activities from which your child should be exempt for health reasons or require modifications:
Please note that it is your responsibility to supply any necessary medical equipment that relates to a specific medical condition.
Medications: List below all medications, including EpiPen, asthma inhaler, over-the-counter or nonprescription drugs, taken regularly. If your child needs to take medication or you expect camp staff to dispense medication to your child during camp hours, you must also complete the separate Medication Dispensing Information, Waiver and Release form.
List all medications. If staff needs to dispense medication, fill out Medication Dispensing Form.
Health Insurance/Physician Information
Permission to Secure Treatment
All camp staff are certified in First Aid, CPR, AED, EpiPen and asthma inhaler assistance. They will take whatever emergency medical measures are deemed necessary for the protection and safety of the camper within their training.
In the event of any emergency, I authorize the Lake County Forest Preserve District to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility if I am unable to be reached first.
Waiver and Release
Please read this form carefully and be aware in registering your minor child/ward for participation in the program or programs listed above you will be waiving and releasing all claims for injuries you or your minor child/ward might sustain arising from that program.
The Lake County Forest Preserve District is committed to conducting its programs and activities in the safest manner possible and holds the safety of participants in the highest possible regard. Participants and parents registering their children in programs and activities must recognize, however, that there is an inherent risk of injury when choosing to participate. The Lake County Forest Preserve District strives to reduce such risks and insists that all participants follow safety rules and instructions which have been designed to protect the participant's safety.
Please recognize that the Lake County Forest Preserve District does not carry medical accident insurance for injuries sustained in its programs and activities. The cost of such medical expense would make program fees prohibitive. Therefore, each person registering themselves or a family member for a program or activity should review their own health insurance policy for coverage. It must be noted that the absence of health insurance coverage does not make the Lake County Forest Preserve District automatically responsible for the payment of medical expenses. Your cooperation is greatly appreciated.
Release of Liability & Permission to Secure Treatment
I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any injuries, damages or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program(s).
I agree to waive and relinquish all claims I or my minor child/ward may have against the Lake County Forest Preserve District and its officers, agents, volunteers and employees as a result of participation in the program.
I do hereby fully release and discharge the Lake County Forest Preserve District and its officers, agents, volunteers and employees from any and all claims from injury, damage or loss with the activities of the program(s) (including transportation services and vehicle operations, when provided).
I further agree to indemnify and hold harmless and defend the Lake County Forest Preserve District and its officers, agents, servants and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising out of, connected with, or in any way associated with the activities of the program(s).
Recreational activities are intended to challenge and engage the physical, mental and emotional resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning and equipment, there is still a risk of serious injury when participating in any recreational activity. All hazards and dangers cannot be foreseen. Depending on the particular activity, certain risks, dangers and injuries may exist due to inclement weather, slips and falls, poor skill level or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defects, inadequate or defective equipment, inadequate supervision, instruction or officiating, and other risks inherent to the particular activity. In this regard, it is impossible for the (District/SRA) to guarantee absolute safety.
In the event of any emergency, I authorize the Lake County Forest Preserve District to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered.
I give permission for my child’s picture to be used in advertisements for the Lake County Forest Preserves.