Energy Explorers Day Camp 2023 Sign-Up Form Today's Date(Required) MM slash DD slash YYYY Member Name (Parent or Guardian of Participant)(Required) First Last Email(Required) Phone(Required)Account Number(Required)Type of SCI REMC Member(Required) Electric SCI Fiber Both Service Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant InformationName of the Child Participating(Required) First Last Grade(Required) 4th Grade 5th Grade 6th Grade School Attending Emergency InformationMother's Name(Required) Phone NumberFather's Name(Required) Phone NumberIn an emergency when the parent/guardian cannot be reached, please contact the following:Name Phone NumberRelationship Name Phone NumberRelationship WaiversAll waivers must be agreed to and signed by the parent or guardian of the child in order to participate in the Energy Explorers Day Camp.Release, Waiver and Indemnification FormMy child, who I have listed as the participant, has my permission to participate in a bucket truck ride at South Central Indiana REMC’s Energy Explorer Day Camp on Friday, June 30, 2023. By signing this release, the undersigned hereby agrees to indemnify, release, waive and hold harmless the REMC, as well as its subsidiaries, directors, officers, employees and agents, from any and all actions, or causes of action, claims, demands, liabilities, loss, damage or expense of whatsoever kind and nature (including attorney fees), which the above-described Participant, and the parents and/or guardian of Participant, if applicable, may hereafter suffer or incur by reason of bodily injury, including death, or by reason of damage to or destruction of any property, including the loss of use thereof, arising out of or during their participation in the bucket truck ride. I am not only giving my permission, but also saying that my child is aware of potential dangers of being lifted in the bucket 20-25 feet, and I have told him/her to comply with the safety rules stated by the trained professionals facilitating the activity. I realize that my child’s cooperation is needed for his/her own safety as well as the safety of others. I grant permission for my child to participate in the bucket truck ride at South Central Indiana REMC's Energy Explorer Day Camp on Friday, June 30, 2023Photo and Video Release(Required)I acknowledge that SCI REMC and participating parties will be taking photos and videos of the event. I acknowledge that these photos and videos may be used on social media and may be used for other advertising. I grant permission for SCI REMC and participating parties to use photos and videos taken that may include my child .
