Name of Camper:
Date of Birth. / Age of Camper:
Name of Parent or Guardian:
Phone Number of Parent or Guardian:
e-Mail of Parent or Guardian:
Participants receive a camp shirt, please indicate size:
Health Information:
Please indicate health insurance coverage (insurance company and policy # if applicable):
Emergency Contact Person:
EMERGENCY NUMBER:
Emergency contact relationship:
List all medical conditions, physical or learning disabilities, any emotional or behavioral problems, and/or any other relevant information:
Drug Allergies:
Food Allergies:
Indicate any medications or special treatments received by the applicant:
Authorization for Medical Treatment - must be completed by Parent/Guardian:
Name of Parent or Guardian:
I (parent or legal guardian) hereby grant permission for said camper, to participate in all phases of the activities for Challenger Learning Center's Camp on June 23- June 27, 2025. It is with my full knowledge and approval that I allow the above-named applicant to participate. I understand and agree that I am responsible as the above-named applicant's parent or legal guardian for providing health insurance to cover any accident and/or health problems resulting from or arising out of the participation of the applicant in the Challenger Learning Center's Summer Camp. I hereby give consent in advance for the personnel of Wheeling University and the Challenger Learning Center to take all necessary steps to provide all necessary medical treatment on behalf of the applicant. In the event of an emergency, I authorize the personnel of Wheeling University and the Challenger Learning Center to arrange for any necessary emergency medical treatment on behalf of the applicant, including but not limited to calling 911. I understand that the Challenger Learning Center will try to contact me as soon as possible in the event of such an emergency. I agree to assume all financial liabilities. I hereby release, discharge, and hold harmless Wheeling University, its employees, and its agents for all responsibility, damages, or causes of action, present or future, resulting from or arising out of the participation of the above- named applicant in the Challenger Learning Center's Summer Camp I understand and agree that if a clause or provision of this release and permission is found by a court to be invalid, that finding shall not invalidate any other clause or provision of this release, which shall continue to be enforceable. I hereby acknowledge that I have/will notify the personnel of the Challenger Learning Center of all special medical needs or other information required by the above-named applicant. I verify that you have my permission to take my camper to the nearest medical facility for emergency treatment and I assume responsibility for payment.:
Hospital of choice:
Physician of choice:
Dentist of choice:
Parents/Guardians, emergency contact and authorized individuals listed below are the ONLY individuals allowed to pick your child up from Camp! IF AN INDIVIDUAL IS NOT ON THE LIST, HE/SHE WILL NOT BE ALLOWED TO PICK UP YOUR CHILD:
Model Release Authorization: The Challenger Learning Center at Wheeling University in Wheeling, WV, and its entities are occasionally visited by news media, video/film crews, or photographers hired by the Chal lenger Learning Center to take promotional or publicity photographs, video, or film. Visiting group chaperones and guests also take photographs, video, or film. There is a possibility that students and adults attending programs will be photographed. I give my consent to authorize the Challenger Learning Center at Wheeling University and its entities the perpetual and worldwide rights in which my said camper appears or otherwise participates, directly or indirectly, visually or audibly, alone or with others, to copyright the same, in its own name or otherwise (and assign my rights throughout the world in such film, photographs, audio recordings, videotape, and/or other digital, electronic, or magnetic media) to use, reuse, transmit, publish, and republish, and otherwise reproduce, distribute, modify, and display the same, in whole or in part, individually or in conjunction with other film, photographs, audio recordings, videotape, and/or other digital, electronic, or magnetic media, and in conjunction with any copyrighted matter, in any and all media now or hereafter known, for illustration, promotion, art, advertising, and trade, or any other purpose whatsoever; and to use his/her name in connection therewith if it so chooses. I on behalf of the applicant camper named minor child hereby release and discharge the Challenger Learning Center at Wheeling University and its entities from any and all claims and demands arising out of or in connection with the use of the minor child's image, likeness, or voice as described above. :
date of application/consent:
Application is not complete until payment has been received. Once payment is received, a confirmation letter will be sent securing your camper s spot in our Summer Camp. Payments can be made on our website under the CAMP page:
