In signing this form, I hereby indicate my permission for the following named child, for whom I am the legal guardian, to participate in the Pamplin Historical Park history camp program. I further state that the child does not suffer from any medical condition or disability that may require special attention or care, unless indicated on the attached application and arrangements have been made to provide the necessary care.

In permitting my child’s participation in the history camp, I hereby agree and hold harmless Pamplin Historical Park, its officers, employees, and agents from any and all liability. I further understand that Pamplin Historical Park reserves the right to remove a repeatedly disruptive child from the program, and that the admission fees are non-refundable.

Print this form, and FAX or mail it to us with your medical and photo release forms at:

Pamplin Historical Park
6125 Boydton Plank Road
Petersburg, VA 23803
( 804) 861-2820