DINO Adventure Day Camp Entry Form 2011

LAST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

FIRST NAME: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

AGE: _____ SEX: M__ F__

STREET ADDRESS: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

CITY: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| STATE: |__|__|

ZIP: |__|__|__|__|__| PHONE#: (____)|__|__|__-__|__|__|__|

E-MAIL: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

T-SHIRT SIZE: YouthS___ YouthM___ AdultS___ AdultM___ AdultL___ AdultXL___

Please Rank Preference Order of Activities:

(1= first choice, 5=last choice) Not every child will do every activity. This ranking will help us to assign sessions.

___ Mountain Biking

___ Outdoor Skills (Camping / Backpacking / First aid etc)
___ Climbing Wall / Zip Line

___ Paddling / Canoeing
___ Navigation / Orienteering / Geocaching

Entry Fee: $25 – Additional children (same family) $20

*Entry must be received one week prior to the Adventure Day Camp

Mail entry with check payable to:

DINO, LLC; PO Box 36395; Indianapolis IN 46236

ALL PARTICIPANTS AND PARENT / GUARDIAN MUST SIGN BELOW- Please read before signing this waiver and release statement. In consideration of the acceptance of my entry, I for myself, any executors, administrators, and assignees, do hereby hold harmless all organizations, volunteers, individuals, businesses, sponsors, and government entities associated with the DINO Adventure Day Camp, directed by DINO LLC, for all claims, damages, actions, whatsoever in any manner arising or growing out of my participation in said event. I attest and verify that I am physically fit and sufficiently trained to participate in this event and assume all risk of participation. Further, I hereby grant full permission of the foregoing to use my name and photographs of me participating in this event for any publicity or promotional purposes without obligation or liability to me.

This constitutes a release and waiver.

Participant Name - Printed: Signature: Parent or Guardian Signature:

________________________ _________________________ _________________________