Pioneer Electric’s 2023 Energy Camp

Participant / Child's Name*

Parent / Guardian's Name*

Are you a Pioneer Member?*

Yes

Child's School*

Home Address*

City*

Zip Code*

Cell Phone Number*

Alternate Phone Number

Email Address*

My child would like to attend Energy Camp on*

June 13-15 in Piqua

June 27-29 in Urbana

My child is going into*

4th Grade

5th Grade

6th Grade

Shirt Size*

Youth Medium

Youth Large

Youth Extra Large

Adult Small

Adult Medium

Adult Large

READ CAREFULLY - THIS IS A RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT*

I consent to the release and indemnity agreement

IN CONSIDERATION of attending Energy Camp at Pioneer Rural Electric Cooperative, Inc (hereinafter the “Pioneer”), on June 13-15 or June 27-29, 2023. THE UNDERSIGNED, for himself/herself and his/her children, their personal representatives, heirs, executors, administrators, and next of kin, acknowledges and represents that he/she has, or will immediately upon entering Pioneer’s property and continuously thereafter, inspect Pioneer’s facility and all portions thereof which he/she enters and with which he/she comes in contact, and he/she further warrants while on-site that if, at any time, he/she feels anything to be unsafe, he/she will immediately advise a member of Pioneer.

I HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Pioneer or its employees, officers, directors and assigns, individually and collectively (hereinafter “Releasees”), from all liability to the undersigned, on behalf of himself/herself and his/her minor children, personal representatives, heirs, executors, representatives, and next of kin, for any and all loss or damage, and any claims or demands therefor on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the Releasees or otherwise while the undersigned is in or upon the property and/or observing activities on or off of Pioneer’s property.

I HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS Pioneer, its employees, officers, directors, agents and assigns, individually and collectively from any and all loss, liability, damage or cost they may incur due to the presence of the undersigned in or upon the property or off property whether caused by the negligence of Pioneer, its employees, officers, directors and assigns.

I HEREBY ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of Pioneer, its employees, officers, directors, agents and assigns while off of Pioneer’s property or upon Pioneer’s property.

THE UNDERSIGNED expressly acknowledges and fully assumes the risk associated with Energy Camp at Pioneer for his/her child/minor. THE UNDERSIGNED further expressly agrees that the foregoing release, waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the State of Ohio and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding, continue in full legal force and effect.

I acknowledge that having my child/minor attend Energy Camp is a privilege. Attendance may be revoked without warning due to my child’s/minor’s behavior. I will immediately make arrangements to pick up my child/minor.

Emergency Medical Treatment

In the event of an emergency, I hereby give permission to transport my child/minor to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency and you are unable to reach me at the above numbers, contact:

Alternate Contact Name*

Alternate Contact Relationship*

Alternate Contact Phone*

Primary Physician*

Phone*

Dentist

Phone

Specific Medical Information

Pioneer will take reasonable care to see that the following information will be held in confidence:

Allergic reactions (medications, foods, plants, insects, etc.)

Does student carry medication with them?

Yes

N/A

If so, when does medication need to be administered?

Name of medication(s):

Immunizations - Date of last tetanus/diphtheria immunization

Does student have a medically prescribed diet?

Any physical limitations?

Has child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.? If so, date and disease or condition:

You should be aware of these special medical conditions of my child:

Parent's/Guardian's Signature*

Date*

Students will be sent an email confirming acceptance into the camp no later than June 1, 2023 with priorty given to children of Pioneer members. Space is limited.

Pioneer Electric 2023 Energy Camp

Do you have a student who is entering 4th, 5th, or 6th grade?

Two options to participate:

Apply Online

Emergency Medical Treatment

Specific Medical Information

Scholarships

Thanks to our Energy Partners: