Valley Mill Cobra Latestay 8/15 Boys Latestay Valley Mill Camp Permission Slip Trip Information Your camper has earned the privilege to participate in a late stay at camp. There is no charge for this activity. Campers will stay at camp and participate in camp activities and cook dinner. Please indicate any dietary or medical needs for your child on this form. If you have any questions, please call 301-948-0220. Pick Up:Campers must be picked up at camp at 8:00 p.m. Please wait outside the office, your camper will meet you there. To Give Permission: By signing this form you give permission for your camper to stay late at Valley Mill Camp. If you would like your camper to attend this activity make sure to indicate this with your digital signature. If you do not want to give permission or if they cannot attend or if you have any questions please call 301-948-0220. Directions to Camp: From Rockville: Go west on Rt. 28 to Darnestown. Turn left on Seneca Rd. (Route 112). Go 2 miles and the Camp is on the right. From Potomac: Follow River Road west until it comes to a T. Take a right on Seneca Rd. (Route 112). Go .7 of a mile and the Camp is on the left. Thank You!!!Select Your Child's Group*Select Your Child's GroupGrizzliesFalconsHawksScorpsCoyotesSharksCobrasPythonsRoadiesGatorsTurkeysOld GroupChild's Name* First Last Parent's Name First Last Parent's Email Parent's PhoneEmergency Contact Name* First Last Emergency Contact Phone*MEDICAL RESTRICTIONS, AND ANYTHING YOU'D LIKE US TO KNOW* My child has no physical, mental or medical condition that would adversely affect his/her ability to participate in the Valley Mill Camp program or that would affect his/her safety or the safety of the group. I agree to inform Valley Mill Camp of any such physical, mental, or medical condition should one develop in the future. * I understand and agree that in participating in the Valley Mill Camp program or using the equipment or facilities of Valley Mill Camp or receiving the instruction of Valley Mill Camp there is the possibility of accidental or other physical injury. I agree to assume the risk of such injury and further agree to indemnify Valley Mill Camp Inc., Seneca Joint Venture and all of their agents, employees, directors, officers, affiliates, successors, and assigns (collectively “Valley Mill Camp”) from any and all liability as a result of my use of the facilities, equipment and instruction offered by Valley Mill Camp. * I agree that I am the Parent or Legal Guardian of the Camper named above, that I am 18 years of age or older, and that I have the legal authority to grant this permission to Valley Mill Camp Inc * By checking the above checkbox, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. Type Name of Signer* First Last Date* Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.