Penn Media Camp Information Sheet

Please use this form to give important information about your camper to Kevin McNulty. This information will only go to Mr. McNulty.
* Required
Camper Full Name *
Your answer
Camper Age *
Your answer
Camper Shirt Size *
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Session attending *
June 8-12, 8:30-11:30 AM
June 8-12, 12:30-3:30 PM
June 15-19, 8:30-11:30 AM
June 15-19, 12:30-3:30 PM
(In South Bend) June 22-26, 8:30-11:30 AM
Parent/Guardian Full Name *
Your answer
Parent/Guardian Phone *
Your answer
Parent/Guardian E-mail *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Camper allergies or medical concerns
Your answer
I, the undersigned, waive and release any and all claims for myself and my heirs against Kevin McNulty, Penn High School, the Center for Mass Media Studies, the Boys & Girls Club of Saint Joseph County, and any of their officers, directors, employees, agents or volunteers for any injuries or illnesses which may directly or indirectly result from participation in the "Media Camp." This waiver and release is valid from the date of my completion of this form, and shall remain effective unless and until modified in writing by the undersigned. I understand that "Media Camp" may, from time to time, record and photograph campers for marketing and archival purposes. As this is a mass media camp I understand that photographs, video, and audio recordings will be made of and by my camper. I acknowledge that it is my responsibility to notify the Kevin McNulty of my desire not to have my camper be photographed or recorded. I hereby grant Kevin McNulty and "Media Camp" permission to use photographs, video, and audio recordings in which my camper appears for marketing, communications, and/or archival purposes. I waive any right to inspect or approve the finished products. *
By submitting this form online, I certify that I am the parent or guardian of the minor named above and have the legal authority to execute the above release and approve the foregoing. *
Please type your full name & today's date in the space below.
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