Parent/Guardian Waiver, Release & Emergency Consent

Camper Name *

First

Last

Date of Birth *

Emergency Contact *

Who should we contact in emergencies? (List at least 1 pwerson other than the parent/guardian and their phone number)

(Check Pickup, all

Authorized Pickup Persons *

Please list all adults who are authorized to pick up your child from camp. Your child will only be released to the parent/guardian or the authorized adults listed below. Lingo Dice may request a photo ID at pickup.

Camp Pickup, Waiver & Policy Form (Check all of them) *

I understand that participation in camp activities may involve ordinary risks, including minor injuries, accidents, illness, allergic reactions, or other unexpected incidents. I agree that Lingo Dice, its owners, instructors, staff, volunteers, contractors, and representatives will not be held responsible for ordinary risks associated with participation, except in cases of gross negligence, willful misconduct, or intentional wrongdoing.
In case of emergency, I authorize Lingo Dice staff or representatives to contact emergency services and/or seek emergency medical or dental care for my child if I cannot be reached immediately. I understand that I am responsible for any medical, dental, ambulance, emergency, or related costs incurred for my child’s care.
I understand that Lingo Dice will provide a snack during camp, but families are responsible for sending lunch with their child each day. I also understand that Lingo Dice cannot guarantee an allergen-free environment.
I understand and agree that my child must be picked up on time at the scheduled dismissal time for their program. A 10-minute grace period will be allowed. If my child is picked up more than 10 minutes late, I agree to pay a late pickup fee of $5 for every 5 minutes of delay.

By typing my full name below and submitting this form, I agree that my typed name serves as my electronic signature. *