Underground Railroad Camp Registration

Step 1 of 3

How many campers? *

Camper #1 Information

Camper #1 Name *

First

Last

Camper #1 Email *

Camper #1 Mobile Phone *

Date of Birth - Camper #1 *

Grade in the Fall - Camper #1 *

Home Address - Camper #1 *

Address Line 1

Address Line 2

City

State

Zip Code

County - Camper #1 *

Camper #2 Information

Name - Camper #2 *

First

Last

Email - Camper #2 *

Date of Birth - Camper #2 *

Grade in the Fall - Camper #2 *

Is the home address the same as Camper #1?

Name - Camper #3 *

First

Last

Email - Camper #3 *

Date of Birth - Camper #3 *

Grade in the Fall - Camper #3 *

Is the home address the same as Camper #1 or 2?

Same as Camper 1
Same as Camper 2
Neither

Medical Needs & Medication Information

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Does the child take any medications that will need to be given while the child is in the care of the summer camp staff at the Peter Mott House? If so, please list medications and instructions for administration.

Parental Consent & Authorizations

Medical Release and Authorization *

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and medication administration. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Peter Mott House and Lawnside Historical Society, and its affiliates including Directors, Educators, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Informed Consent and Acknowledgement *

I hereby give my approval for my child’s participation in any and all activities prepared by Peter Mott House and Lawnside Historical Society during the selected camp. In exchange for the acceptance of said child’s candidacy by Peter Mott House and Lawnside Historical Society, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Peter Mott House and Lawnside Historical Society and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Peter Mott House and Lawnside Historical Society including all educators and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Confirmation

By acknowledging and signing below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.

Photography *

I authorize the taking of my child's photograph during their time at Colonial Pennsylvania Plantation. I understand that such photographs my be used as part of promotional material or on CPP Website/Social Media in the future.

Camper #1 Information

Camper #2 Information

Camper #3

Parent/Guardian Information

Emergency Contact

Medical Needs & Medication Information

Parental Consent & Authorizations

Confirmation

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Trip Info

If this is a group of 7 or more individuals, please use our Group Tour Form by exiting this dialogue box.

Visitor Information

Contact Information

Thank you for submitting your tour request.