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Spring Break Camp Parent Waiver Form

(636) 944-6001

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Fill out online or click HERE for printable PDF.

Must fill out ONE Waiver Form for each camper.

Spring Break Camp Waiver Form

Participant's First Name *

Participant's Last Name *

Participant's Age *

Participant's Date of Birth: Month/Day/Year *

Home Address: Street, City, State and Zip *

Primary Phone Number *

Primary Email:

Primary Contact's Name: *

Primary Contact's Relation to Participant *

Primary Contact's Cell Phone Number *

Primary Contact's Work Phone Number *

Secondary Contact's Name: *

Secondary Contact's Relation to Participant *

Secondary Contact's Cell Phone Number *

Secondary Contact's Work Phone Number *

Emergency Contact *

Name - Other than Primary or Secondary Contact

Emergency Contact's Relation to Participant *

Emergency Contact Phone Number *

Please list Participant's Current Medications:

Medications are to be held by Day Camp staff. Staff will remind your child to take medications if we are made aware of dosages and times.

Please list Participant's known Allergies:

Primary Care Doctor's Name:

Primary Care Doctor's Phone Number:

Does your child need accomodations (additional support) to participate? *

YES

If yes, please contact Patrick Logel, Recreation Specialist at (636)255-6146 or email patrick.logel@stcharlesparks.com

By checking the box below I hereby grant permission for (me/my child) to participate in Recreation Programs sponsored by the St. Charles Parks and Recreation Department. *

I hereby grant permission.

I do hereby give St. Charles Parks and Recreation Department or person(s) or agencies operating in its authorized behalf complete permission to take (me/my child) on any trip which is planned and supervised by the City of St. Charles Parks and Recreation Department. *

YES

I do hereby give St. Charles Parks and Recreation Department or person(s) or agencies operating in its authorized behalf complete permission to take (me/my child) to and from designated program sites in insured vehicle provided by the City of St. Charles Parks and Recreation Department. *

YES

I do hereby give St. Charles Parks and Recreation Department or person(s) or agencies operating in its authorized behalf complete permission to take pictures of (me/my child) during Department sponsored events and use such pictures in promotional materials for the City of St. Charles Parks and Recreation Department. *

YES

In the event that I cannot be reached in an emergency I hereby give permission to the physician selected by the City of St. Charles Parks and Recreation Department to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for (me/mychild) as named above at my expense. *

YES

My child will be walking/riding a bike to and from camp. *

YES

*The following individuals are authorized to pick up my child
(other than parent/guardians listed above)

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

I understand (I/my child) can be excluded at any time during the program by the City of St. Charles Parks and Recreation Department staff if it is judged that (i/my child)(have/has) hampered the safety, welfare or enjoyment of other participants in the program. *

I understand

*PLEASE REVIEW THE ABOVE INFORMATION BEFORE SUBMITTING THIS FORM.* *

Find a Park

The City of Saint Charles has 26 parks serving residents and visitors. They offer a wide variety of opportunities from swimming to nature trails.

Berthold Square Park Blanchette Park Boone’s Lick Park Boschert Greenway Centennial Greenway Circle Drive Park DuSable Park Forget-Me-Not Fountain Lakes Park Fox Hill Park Frenchtown Park Frontier Park Greystone Park

Heatherbrook Park Jaycee Park Kister Park Kiwanis/Schneider Park McNair Park New Park Development Schaefer Park St. Charles Soccer Complex Park Vogt Brothers Park Wapelhorst Park Webster Park Westwinds Park Woodlands Park

How Can We Help?

St. Charles City Parks & Recreation is always happy to provide you with additional information. Feel free to contact us using the phone numbers below, or our online contact form. We look forward to hearing from you!

1900 Randolph Street, St. Charles, MO 63301

Park Administration Office: 636-949-3372

Office Hours: Monday - Friday, 8:00 AM to 5:00 PM

Name *

Email *

Questions or comments *

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