2019 Camp 911

General Information & Emergency Contact Form

To be filled out by parent or guardian.  This information will be kept in a secure location with access by camp health officer or camp directors only.  We will send important academy information via email, please include at least one below.

Child Information

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Mother/Guardian

Father/Guardian

In the event of an emergency during the academy we will attempt to contact a parent. Please list below the name and contact information for a grandparent, aunt, uncle, friend, neighbor, etc. that we may call if we are unable to reach either parent.

Childs Medical Information and History (PARENT)


Medical History

ADHD *
Convulsions/Seizures *
Hemophilia *
Asthma *
Diabetes *
Heart Trouble *
Cancer/Leukemia *
High Blood Pressure *
Kidney Disease *

Liability Release Form (PARENT)

Request is hereby made for permission for my son/daughter(s) to participate in the Camp 911 and related exercises conducted by the Boone County Sheriff’s Office/ Lebanon Fire Department.

In consideration of receiving such permission, I hereby agree to release and hold harmless the County of Boone, Boone County Sheriff’s Office, City of Lebanon, Indiana, the Lebanon Fire Department, and their agencies, officers, and employees, from any and all liability for any injury my child might suffer directly or indirectly arising from the participation of my child in the Camp 911. This release is freely and voluntarily entered into by me in consideration of the grant of permission for my child to participate in the Camp 911, and this release shall be binding upon me and my heirs, beneficiaries, and personal representatives.

Media/Photo Release Authorization (PARENT)

As a parent of a child enrolled in the Boone County Sheriff’s Office/ Lebanon Fire Department Camp 911, I understand and agree to the following conditions:

1.  Members of various news media outlets will be on site at our academy from time to time for the purpose of recording and reporting to the general public on the success of our program. This may include newspaper, radio, and television.

2.  The Department may employee a person to record most of our camp on professional grade television recording equipment for the purposes of creating promotional videos for future events, creating souvenir tapes for the participants, and to create training videos to use in other aspects of our Public Education mission.

3.  The Department will be taking photographs during the week, which may be used on our official Department Website or other promotional outlets.

4.  Participants and staff members under the age of 18 will only be identified to the media and general public by their first names.

5.  A Shutterfly Account will be created for you to access pictures. The account will only allow users that we invite to look at the pictures.

6.  My child will only be eligible to participate in the academy if I agree to these conditions and sign below. Refusal to sign this form will prohibit your child from attending our camp.