Camp LPH Registration

In the fall of 2022, my camper will be in the ___ grade.

Used for statistics and group assignment purposes only.

Please provide first and last name, phone number, and email address

Name, phone number(s), email address. Will be included on all camp information emails in advance and will be contacted in case of emergency immediately following primary contact.

Are allowed to pickup camper and can be contacted in an emergency if primary and secondary contacts are not reachable. Please include name, relationship to camper, and phone number.

Does your child have any condition (physical, emotional, or cognitive) of which Camp staff should be aware? Please also include anything you think we should know about your camper to ensure that they have the best experience possible.

For example: “my camper needs many reminders to drink water…”, or “my camper gets overwhelmed by many instructions all at once, please give them short, clear instructions…”

Does your child require any medication that might need to be administered during camp hours?

Please list medications and procedures and any other information we should know (ie, prone to dehydration, etc).
Please keep in original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, dosage, and frequency of administration • Please provide sufficient medications for the entire camp session • All medications will be administered/stored by History Center Staff.
If none, enter N/A

Thomasville History Center staff will take photographs and video of campers engaged in activities throughout the camp. I hereby give permission to the Thomas County Historical Society, Inc. DBA Thomasville History Center to use photographs that include my child to publicize Camp Dawson, the Lapham-Patterson House, and/or the Thomasville History Center.

I hereby give permission for my child to participate in all planned excursions off the Thomasville History Center’s campus during Camp Dawson, June 5-9, 2023 and/or Camp LPH June 20-22, 2023.

A complete list of planned excursions will be available closer to camp.

I hereby authorize the Thomas County Historical Society, Inc. DBA Thomasville History Center employees and/or camp staff to act in accordance to their best judgment in any emergency requiring medical attention for my child. Further, in the event of an illness or injury to my child, I give the attending physician permission to administer treatment while continuing to attempt to contact the parent, guardian or designated individuals listed on this submission.

I understand and have been advised that this program is not licensed by the Bright from the Start: Georgia Department of Early Care and Learning and is not required to be licensed. Bright from the Start does not regulate or routinely inspect this program. The Thomas County Historical Society, Inc. DBA Thomasville History Center carries Business Liability Coverage (bodily injury, property damage, personal and advertising injury). Proof of insurance may be shared upon request.

Shhhh! It’s a surprise, but we will be joined by our friends at Fun Sized Farms on Tuesday, June 6. They have asked that we include their waiver in our registration. If you have any questions, please contact Amelia, amelia@thomascountyhistory.org.

Petting Farm Waiver of Liability

By signing this agreement, you give up the right to sue for any injuries or damages howsoever caused, Fun Size Farms, LLC of Boston GA. and owners, employees, representatives, officers, and agents

· WARNING

· Under Georgia law, a livestock activity sponsor, livestock professional, or owner of a livestock facility is not liable for an injury to or the death of a participant in livestock activities resulting from the inherent risks of animal activities, pursuant to Chapter 12 of Title 4 of the Official Code of Georgia Annotated.

I, the undersigned, have read and understand the Georgia Livestock Liability Law. I hereby release, waive responsibility, discharge and covenant not to sue Fun Size Farms LLC located at 626 E Jefferson St Boston GA 31626, its representatives, agents, directors, sponsors, or volunteers, jointly or individually, for any loss or claim as a result of personal injury or property damage which might arise from my participation in any program or activity directly or indirectly involving Fun Size Farms LLC, whether or not upon premises then occupied by Fun Size Farms LLC.

I understand that there are obvious and non-obvious inherent risks always present in livestock activity despite all safety precautions. No animal is a completely safe animal, and if frightened or provoked may divert from its training and act according to its natural survival instincts which may include, but are not limited to, biting, striking, kicking, bolting, and running from perceived danger, which can cause injury or death to me or others. I understand there are certain inherent with handling animals, and I accept those risks.

I do permit my child to participate in the petting farm.

I consent and give permission to allow photographs and/or videos to be taken of Participant during the activity. I further give consent and permission that any such photographs and videos may be published and used by Fun Size Farms LLC and its agents to illustrate and promote its experience and programs.