2015 Nature Explorers Registration Form (Rising 1st to 3rd graders)

Transcription

1 Information 2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Camper Name: DOB: Parent/Guardian Name(s): Address: City: State: Zip: Home Cell Work *If emergency contact is different from parent/guardian please include that information below: Camper T-shirt Size: Youth: small med large Adult: small med How did you learn about Camp Muddy Sneakers?

2 Enrollment Check the box for the session or sessions your child would like to attend. Please see our camp website for more details: campmuddysneakers.org Brevard Sessions (Transylvania County) June 15 June 19 July 13 July 17 July 27 July 31 August 10 - August 14 Hendersonville Sessions (Henderson County) June 22 June 26 July 6 July 10 July 20 July 24 Asheville Sessions (Buncombe County) June 29 July 3 August 3 August 7 Payment Total number sessions $ Payment Due (total number sessions x $195) Make checks payable to Camp Muddy Sneakers and mail your registration packet to: Camp Muddy Sneakers P. O. Box 146 Brevard, NC 28712

3 Release/ Consent/ Permission Statement/ Assumption of Risk I have reviewed the program schedule of the camp and my child has permission to engage in all prescribed camp activities. I acknowledge that some activities are potentially hazardous and involve risk, and I release Camp Muddy Sneakers and Muddy Sneakers from any liability whatsoever for any risks that are inherent in the activity. Camp Muddy Sneakers activities occur in Pisgah Nation Forest (NF), Dupont State Recreational Forest (SRF), Asheville City Parks, and some privately protected property. Activities within Pisgah NF and DuPont SRF are authorized under special permit. Camp Muddy Sneakers reserves the right to dismiss any camper who violates the camp rules or whose conduct is determined by Camp Muddy Sneakers to be detrimental to self, other campers, or the general welfare of the camp. No refund will be made in case of dismissal. Each registration is a commitment to attend Camp Muddy Sneakers. Cancellation is subject to a $50 nonrefundable fee. In the event that you need to cancel, half of the total fee is refundable if cancelled 30-7 days prior to the camp session start date. If cancellation takes place 7 days prior to the camp session start date, none of the total is refundable. Registration is nontransferable. By my signature, I acknowledge that I have read and agree to the contractual terms and Camp Muddy Sneakers policies. Date: Parent or Guardian signature: *Please print and mail the Medical Release Form with payment and registration application. The Medical Release Form may be found at

4 Medical and Liability Release Form *To be completed and submitted upon registration* Camper Name: DOB: Legal Guardian Name: Emergency Contact Name: Physician Name: Insurance Company/ Policy # Please be as thorough as possible when filling out the information below: List any physical restrictions/limitations or medical conditions we should be aware of: List any behavioral conditions we should be aware of: List any medication, when taken, and for what condition: List the camper s allergies to food, plants, insects or medications and the reaction to each:

5 INITIALS: My child has permission to participate in all sessions and activities. In case of an emergency, I request and authorize any physician, hospital, and health care provider to provide medical treatment promptly, whether or not I may be contacted and informed. INITIALS: I am the legal guardian of, who is under the age of 18 and wants to participate in Camp Muddy Sneakers. In consideration of my child s participation in the program, I hereby release and discharge Muddy Sneakers, it s employees, agents, volunteers, and assigns (the Releases ) from any and all liability, claims, claims for relief, damages, actions, causes of action and actionable wrongs of any kind, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, arising at law or in equity as a result of any and all actions and /or omissions of Muddy Sneakers, whether such liability or claim arises from an injury occurring at the camp location. INITIALS: I understand that the Camp Muddy Sneakers staff is not required to administer injections or medications or to perform medical procedures except in the case of life threatening emergency. I understand that Camp Muddy Sneakers staff will allow participants with parental permission to self administer medication and/or injections where such medication and/or injection is physician ordered and directed. I further authorize Camp Muddy Sneakers staff to examine and render emergency or urgent medical care as they deem necessary. INITIALS: I consent and authorize Camp Muddy Sneakers to use my child s photograph for educational and public relations purposes (will not contain your child s name). RELEASE/CONSENT/PERMISSION STATEMENT This health history is completed as far as I know and if changes occur in health related conditions, I will contact Camp Muddy Sneakers. I understand that information on this form will be shared on a need to know basis with camp staff. I have reviewed the program and activities of the camp and the person described herein has permission to engage in all prescribed camp activities except as noted. AUTHORIZATION FOR TREATMENT: I hereby give permission to the medical personnel selected by the camp to order x-rays, routine tests, treatment, and necessary transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the medical personnel selected by the camp to secure and administer treatment, including hospitalization, injection, anesthesia, or surgery for this child as named above. Date: Parent/Guardian Signature: (signature of both parents/guardians required if not married) Please this form to lindsay@muddysneakers.org OR mail it to Camp Muddy Sneakers, PO Box 146, Brevard, NC 28712