Summer Camp Enrollment Form | Atlanta History Center

Child's Name*

First Last

Child's Date of Birth*

Grade in 2021–2022 School Year*

Choose Camp Type*

Select All
History Camps
Writing Camps

Choose Camp Date(s)*

Select All
All of History’s a Stage (June 6–10)
Wonders of the Ancient World (June 13–17)
Heroes of History (June 20–24)
3, 2, 1… Blastoff! History of Space Exploration (June 27–July 1)

Any cancellation on or before Friday, May 27, 2022 will require a $175 fee per camp. No refunds can be made for cancellations after Friday, May 27, 2022. Camp changes/modifications require an administrative fee of $50. Camper(s) picked up after their designated time, parents/guardians will be charged $1 per minute, and late pick-up payment must be paid upon arrival.

Choose Camp Date(s)*

Select All
What if?…: Historical Fiction Writing (June 6–10)
FUN-damentals of Writing (June 13–17)
Script It! Writing for Stage and Screen (June 20–24)
Story Forge: Role Playing Games (June 27–July 1)

Any cancellation on or before Friday, May 27, 2022 will require a $175 fee per camp. No refunds can be made for cancellations after Friday, May 27, 2022. Camp changes/modifications require an administrative fee of $50. Camper(s) picked up after their designated time, parents/guardians will be charged $1 per minute, and late pick-up payment must be paid upon arrival.

T-shirt size*

Sizes Youth: YXS | YS | YM | YL | YXL Adults: S | M | L | XL | 2XL | 3XL | 4XL

Primary Parent / Legal Guardian Name*

First Last

Primary Parent Email*

Primary Parent Phone*

Secondary Parent / Legal Guardian Name

First Last

Secondary Parent / Legal Guardian Email

Secondary Parent / Legal Guardian Phone

Emergency Contact No. 1 Name*

First Last

Emergency Contact No. 1 Phone*

Relationship to the Child*

Emergency Contact No. 2 Name*

First Last

Emergency Contact No. 2 Phone*

Relationship to the Child*

Authorized Pickup No. 1 Name*

First Last

Please list the name and phone number of the person authorized to pick up your child. You must provide written notice to the Summer Camp staff if anyone else will be picking up your child. If it is the same as parents and emergency contacts, please write "same" in the name field listed below.

Authorized Pickup No. 1 Phone*

Relationship to the Child*

Authorized Pickup No. 2 Name*

First Last

Please list the name and phone number of the person authorized to pick up your child. You must provide written notice to the Summer Camp staff if anyone else will be picking up your child. If it is the same as parents and emergency contacts, please write "same" in the name field listed below.

Authorized Pickup No. 2 Phone*

Relationship to the Child*

First Aid Medical Authorization*

I authorize the Atlanta History Center to give my child, named above, first–aid treatment for minor abrasions, insect bites, and stings.
No, the Atlanta History Center is NOT authorized the Atlanta History Center to give my child, named above, first–aid treatment for minor abrasions, insect bites, and stings.

Non–Prescription Medical Authorization*

I authorize the Atlanta History Center to give my child, named above, first-aid treatment for minor ailments, with NON–PRESCRIPTION medications (i.e. Benadryl or Tylenol).
No, the Atlanta History Center is NOT authorized the Atlanta History Center to give my child, named above, first-aid treatment for minor ailments with NON-PRESCRIPTION medications (i.e. Benadryl or Tylenol).

Allergies*

Please list all allergies/restrictions (food, drugs, insects, sunscreen, insect repellent, etc.):

Special problems or restrictions*

Please list special problems or restrictions—including how participation in activities should be adjusted

Medical Needs*

Yes
No

Prescription Medication Authorization: This information should be filled out only for those children who are on prescribed medication(s). Please provide medication on a daily basis in a container clearly marked with the child's name, the dosages, and the time(s) the medication should be given.

Medication*

If answered yes, please provide medication below. If no, please write N/A.

Dosage*

Times of dosage*

Medical Info*

Physician's Name*

Physician's Phone Number*

Emergency Procedures (1/2)*

In an emergency, I direct the Atlanta History Center to follow these procedures:

Emergency Procedures (2/2)*

I agree.

If it is not possible to carry out the above special instructions, I understand that the Atlanta History Center will use its judgment to seek the best emergency care possible. If emergency care is required, and a parent or guardian cannot be reached, I authorize the Atlanta History Center to call for such medical care or to transport the child to the appropriate clinic or hospital. This authorizes the emergency medical care provider to carry out the care deemed necessary for the child where normal permission is unavailable. I agree to pay all costs associated with such medical care and related transportation for the child.

Multimedia Waiver*

I agree.

I, the parent or guardian of the above-named child, on behalf of myself, my heirs, executors, administrators, legal representatives, and assigns, grant to the Atlanta Historical Society, Inc. (“AHS”), its officers, members, employees, contractors, legal representatives, agents, successors, licensees, and assigns (“Releasees”), permission to photograph or otherwise record, and use, reuse, publish, and republish audio, photographs, video, and other visual images of my child (“representations”) in connection with AHS activities. I understand that Releasees may publish the representations without notification and I waive any right to inspect or approve the representations or any copy. I grant Releasees permission to crop or otherwise alter such representations, and to create derivative works from the representations. I understand that the representations may be used by the AHS in print or electronic form, in media such as newsletters, magazine, brochures, websites, press releases, art, editorials, and displays. I waive any right to royalties or other compensation related to use of the representations, and grant permission to Releasees to offer the representations for use in other publications, such as newspapers covering AHS activities. I hereby discharge and release forever any claims related to use of the representations, including any claims for libel, violation of any right of publicity or privacy, and misappropriation, and agree not to sue Releasees for such use. I understand that AHS shall not print or publish the child’s name or contact information in any AHS publication without my express written consent. I also understand and agree that the AHS may cause to be used, reused, published, and republished any artwork or other product created by the child in connection with AHS activities. As a parent or guardian of Participant, a minor, named above, I acknowledge that I am authorized to sign this agreement. I acknowledge and agree that I have read this document, I am signing it freely, and that by signing this release, Participant and I voluntarily agree to be bound by its terms. I understand that I am responsible for the obligations and acts of Participant as described in this document. By checking "I agree" below, I acknowledge this constitutes my electronic signature.

Waiver and Release of Liability*

I agree.

I, the parent or guardian of the above-named child, on behalf of myself, my heirs, executors, administrators, legal representatives, and assigns, grant to the Atlanta Historical Society, Inc. (“AHS”), its officers, members, employees, contractors, legal representatives, agents, successors, licensees, and assigns (“Releasees”), permission to photograph or otherwise record, and use, reuse, publish, and republish audio, photographs, video, and other visual images of my child (“representations”) in connection with AHS activities. I understand that Releasees may publish the representations without notification and I waive any right to inspect or approve the representations or any copy. I grant Releasees permission to crop or otherwise alter such representations, and to create derivative works from the representations. I understand that the representations may be used by the AHS in print or electronic form, in media such as newsletters, magazine, brochures, websites, press releases, art, editorials, and displays. I waive any right to royalties or other compensation related to use of the representations, and grant permission to Releasees to offer the representations for use in other publications, such as newspapers covering AHS activities. I hereby discharge and release forever any claims related to use of the representations, including any claims for libel, violation of any right of publicity or privacy, and misappropriation, and agree not to sue Releasees for such use. I understand that AHS shall not print or publish the child’s name or contact information in any AHS publication without my express written consent. I also understand and agree that the AHS may cause to be used, reused, published, and republished any artwork or other product created by the child in connection with AHS activities. As a parent or guardian of Participant, a minor, named above, I acknowledge that I am authorized to sign this agreement. I acknowledge and agree that I have read this document, I am signing it freely, and that by signing this release, Participant and I voluntarily agree to be bound by its terms. I understand that I am responsible for the obligations and acts of Participant as described in this document. By checking "I agree" below, I acknowledge this constitutes my electronic signature.

Location Acknowledgment*

I acknowledge the location.

As a parent or guardian of Participant, a minor, named above, I acknowledge that all Atlanta History Center 2022 Summer camps will be taking place on the Buckhead campus located at 130 W Paces Ferry Road NW, Atlanta, GA 30305.

Safety Guidelines*

I agree to the Safety Guidelines.

o Although masks are not required, we strongly encourage participants to wear them based on their personal comfort level.
o Stay home if you do not feel well or are exhibiting symptoms of COVID-19.
o Practice social distancing by maintaining at least 6 feet of distance between you and others.
o Wash your hands frequently and practice good hygiene when coughing or sneezing.
o Follow all staff instructions.
o Under Georgia law, there is no liability for an injury or death of an individual entering these premises if such injury or death results from the inherent risks of contracting COVID-19. You are assuming this risk by entering these premises.

Electronic Signature (1/2)*

I agree.

As a parent or guardian of Participant, a minor, named above, I acknowledge that I am authorized to sign this agreement. I acknowledge and agree that I have read and completed this entire online submission, I am signing it freely, and that by agreeing to this submission, Participant and I voluntarily agree to be bound by its terms and the terms of use (www.atlantahistorycenter.com/terms). I understand that I am responsible for the obligations and acts of Participant as described in this submission By checking "I agree" below and entering my initials (or signing), I acknowledge this constitutes my electronic signature for this online submission. By checking "I agree" below, I acknowledge this constitutes my electronic signature for this online submission.

How did you hear about us?*

Electronic Signature (2/2)*

Please enter your full name for this online submission.

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