Camper's Last Name:
Camper's First Name:
Camper's Date of Birth:
Camper's T Shirt Size(Adult)
Highest Maturity Rating camper is allowed:
Last Grade Completed:
Photo of camper.
Camper's Home Address
Secondary Phone Number:
Camper Pick Up:
For safety measures all Campers will need to be signed out by a selected parent/guardian listed above or one of the following (photo ID must be shown at each pick up; a copy of a photo ID may be provided to be kept on file):
Medications taken for current medical conditions (Asthma, Allergies, Etc.): (If none, please type "None")
Medications taken occasionally (headaches, etc):
Will these or any other medication be brought to camp with you?
If so, which medications
Medical Insurance Provider
Plan or Group #
Insurance ID or Member #:
I understand participation in the camp is completely voluntary and agree that the camp is provided through Southeast Missouri State University to enhance my child’s education and that NO INSURANCE COVERAGE EXISTS THROUGH SOUTHEAST MISSOURI STATE UNIVERSITY TO COVER ANY CLAIMS THAT MAY ARISE OUT OF MY CHILD’S PARTICIPATION IN THE CAMP.
RISK AND RESPONSIBILITY: Although reasonable precautions are taken to provide proper organization, instruction, and equipment for your child’s participation in the Summer Camps at Southeast Missouri State University, there can be no guarantee of absolute safety against injury and accident. There are elements of risk in any sport or program involving physical exertion and risks taken; individually and/or collectively during activities, and in the use of any equipment in connection with the activities. I, on behalf of myself and my child, understand that my child may be involved in activities, including but not limited to, arts and crafts, baseball, basketball, soccer, team-building initiatives, tennis, games, and/or other physical undertakings. I acknowledge that participation by my child in any activities is voluntary and that my child may decline to participate in any activities.
MEDICAL: I hereby authorize any medical treatment deemed necessary in the event of any injury to my child while participating in the activities. I have appropriate insurance or, in its absence, I agree to pay all costs of medical services and medical transport as may be incurred on behalf of my child.
TRANSPORTATION: I understand and agree that on some occasions, my child must arrange his/her own transportation related to/during the camp and/or on some occasions Southeast Missouri State University may arrange transportation for my child. I further understand that my child’s decision to accept transportation from Southeast Missouri State University is completely voluntary and accepted at his/her own risk that he/she is not required to accept such transportation, and that such transportation will not be covered by any Southeast Missouri State University insurance. If my child arranges his/her own alternate transportation, I understand that he/she must provide his/her own automobile collision and liability insurance, at his/her expense if my child chooses to drive. Further, I understand and agree that whatever alternate mode of transportation he/she may choose will not be covered by any insurance from Southeast Missouri State University.
SEMO Camp Parent Guide:
As Parent/Guardian, I have read and understand the
SEMO Camp Parent Guide
I hereby grant permission for the above stated Camp participant to appear in still or motion pictures for educational, promotional, or other proper purposes only.
In the event that the University would need to cancel your designated camp a full refund will be returned back to participant and/or family in the form of a University check. In the event that you, the participant, and/or family would need to cancel your registration, you will receive a full refund up until 4 weeks from the camp. If you cancel within 4 weeks of the camp you will receive partial refund. Late cancellations fee is $20.00 from your camp registration cost.
The electronic signature provided confirms I have read and fully completed the above information and agree to the terms and conditions in order for my child to participate in any and all camp activities unless specified above. I acknowledge the information I have given is correct to the best of my knowledge. Furthermore, I give permission for the camp host and Southeast Missouri State University staff to provide and authorize any medical treatment necessary.
Please type in your first & last name. This will serve as your electronic signature. Electronic submission of this form serves in the same capacity as an official signature.
First and Last Name
Esports Camp Sessions:
If the camp you wish to register for does not appear in the list, it may be at capacity.
To be placed on the waiting list please contact the Student Recreation Center at 573-651-2105.
There are NO CAMP SESSIONS AVAILABLE for registration.
****Space for campers will not be reserved unless payment is made.