Blue Sky Adventure Camp - Registration Form

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Eileen Cain
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1 Blue Sky Adventure Camp - Registration Form Please complete this registration form, sign it and return it with a $100 per week deposit owed for camp registration. Please note that a single registration form is for one child in one camp. Required Items: Registration form; Camp Cancellation form; Medical and Health History form; Date of last physical and a good health statement signed by the child s doctor; List of child s allergies; and a list of up to date immunizations. Child s Name: Gender: M / F Date of Birth: / / Address: City State ZIP Parent/Guardian 1: Home Phone: Business/Cell Phone: primary Parent/Guardian 2: Home Phone: Business/Cell Phone: primary Please select dates and additional services on the back before you complete the table below. Thank you. Daily Program Itemized Charges and Optional Services Times Fee per week Number of Weeks Amount Due 7 9 Years Old 9:00am 4:00pm $ July 3, 5, 6, 7 $ Years Old* 9:00am 4:00pm $ July 3, 5, 6, 7 $ Before Care 7:30am 9:00am $45.00 After Care 4:00pm 5:30pm $45.00 Discounts are provided per each transaction $1,000 = 5% off $1,500 = 10% off Discount Applied *Price includes all off-site kayaking. Deposit Due ($100/week) Total Due (by June 1) Name on Card: Card #: Exp.: / Parent/Guardian Signature: Date: / / I agree that Manchester Athletic Club may take, use and publish photographs and/or video of my child for use in publications. I consent to my child s participation in all off-site activities with Manchester Athletic Club understanding that I will be notified at least one day in advance of all trips. I waive any right to claim against Manchester Athletic Club, its trustees, employees and authorized chaperones, and liability for injuries to my child arising out of said activities. Yes No This form must be signed by a parent/legal guardian to complete registration. A Separate form and payment are required if your child is attending more than one program offered at Manchester Athletic Club. In accordance with Massachusetts Department of Public Health regulations: No child may attend camp without completed immunizations and health history forms on site. Failure to submit forms will cause your child to be excused from camp. No refunds will be given. You may request copies of our policies for background checks, health care, and discipline as well as our procedures for filing grievances.

2 Please check the appropriate weeks and times on the calendar below: Attend Before Care JUNE 2016 After Care Week Quality Special Events Field Trip Alertness OPENING DAY / Hoodsie Mania Day Bridge Jumping Essex Gratefulness Face Painting Day IMAX Movie Enthusiasm Smores Day Sky Zone Attend Before Care JULY 2016 After Care Week Quality Special Events Field Trip 3-7 Flexibility Camp Wide BBQ Laser Quest Creativity Counselor Talent Show Gymja Warrior Perseverance Live Animal Show Bridge Jumping Essex Attend Before Care Generosity Game Show Mania Canobie Lake Park AUGUST 2016 After Care Week Quality Special Events Field Trip 31-4 Initiative Fire Foam Day Water Country 7-11 Determination Ice Cream Smorgasboard Ipswich River Canoe Endurance Italian Ice Day North End Trip Courage Lost & Found Fashion Stage Fort Park & BBQ Total Total Total NOTE: If your camper is 10+ (or will be turning 10 this summer), please fill out the ERBA Release Agreement for kayaking and submit with your registration form. Be sure to sign in all places and fill out 2 pages! Thank you.

3 Camp Change & Cancellation Policy Summer Camps 2017 Effective January 1, 2017 Please review this information, sign it and return it with registration. $100 deposit is due at time of registration for each child for each week of Summer Camp. $20 deposit is due at time of registration for each child for each day of Summer Camp. Camp deposit is fully refundable up to June 1st. After this date refunds will be processed only for the exception of medical inability to attend Camp with physicians note provided. Balance of tuition due must be paid 2 weeks prior to the start of Camp. No Camper will be permitted to check-in or attend Camp unless tuition is paid in full. If you withdraw your Camper, your Camper fails to attend, or experiences incomplete attendance for any reason after June 1st, no refunds will be made. Weekly Campers may switch weeks at any time without penalty - two weeks in advance - provided space is available in the Camper s age group. Day Campers may switch days at any time without penalty - 48 hours in advance - provided space is available in the Camper s age group. Day Campers are requested to register for each day in advance to provide MAC Camp staff the opportunity to manage staff-to-camper ratios. Drop-in Day Campers who are approved for Camp, but not registered for the day of arrival, will be charged a $10 late registration drop-in fee upon arrival. Discounts will not be provided for registrations accepted after July 1st. Family Discount Policy: Each Camp registration transaction over $1,000 will receive a 5% discount. Each Camp registration transaction over $1,500 will receive a 10% discount. Separate Camp registration transactions cannot be combined for discounts. Parent/Guardian Print Name: Parent/Guardian Signature: Date: / / * By signing this policy form, I agree to the terms and conditions stated above *

4 Medical & Health History Thank you for enrolling in MAC CAMPS. Please complete the following information and fully sign and date all designated areas. You must also provide proof of your child s Physical within the last 18 months. You must also provide an immunization record for your child. Both of these additional documents are required for camp. Please complete all paperwork and send to us at: 8 Atwater Ave, Manchester, MA or fax to or scan and send to camps@manchesterathleticclub.com Name: DOB: AGE: Camp: Parent/Guardian: Day Phone: Cell: Parent/Guardian: Day Phone: Cell: If not available in an emergency, notify: Name Phone Physician s Name: Phone: Address: Dentist s Name: Phone: Address: Please check if you have a copy of your child s Physical Immunization Record HEALTH HISTORY (please circle) Asthma Diabetes Behavior Migraines Seizures Allergies: Other Please list all medications your child takes daily: All medications used during the camp session must be checked in directly with the Health Supervisor on the first day of the session. A Medical Information Sheet must accompany all medications. Currently the State requires that all campers carry his/her own Epi-Pen or inhaler on their person after having checked them in with the camp Health Supervisor. Do not send medications prior to the start of camp. I give permission for my child to self-administer medications (Inhaler/Epi-Pen) if the Health Supervisor and physician determines it is safe and appropriate (please check one) Yes No Daily Prescription Medications require a separate form and a signed Physician s Order. HEALTH HISTORY (please check all that apply) I give permission for the Health Supervisor (or personnel desgnated by the Health Supervisor) to administer the following medication to my child. Tylenol Advil Benadryl Tums Epi-Pen Inhaler I give permission for the Health Supervisor to share appropriate medical information concerniing any above listed health modifications and information. The undersigned parent/guardian of (print child s full name): consents Manchester Athletic Club taking such child to the hospital, when in the opinion of the personnel of the MAC, treatment appears necessary and in circum-stances where the parent or guardian cannot be reached in a timely manner to give consent. The consent will remain in effect as long as the above child attends Manchester Athletic Club programs, or until I revoke my consent in writing. Name of Guardian: Relationship to child: Signature: Date:

5 ERBA Release Agreement I, the undersigned, am renting a sea kayak from Essex River Basin Adventures, Inc. (ERBA). I acknowledge that I have read the Assumption of Risk statement on the reverse side of this page and fully understand that there are certain elements of danger inherent in outdoor activities which I am about to undertake, and which are beyond the control of the staff of ERBA, and that participating in a tour or program may entail unavoidable risks, personal injury, loss of life, and loss of or damage to property. My participation in this activity is purely voluntary. In consideration of ERBA furnishing services and materials to enable me to participate in this program, I hereby assume all risk of injury or loss of life to myself, and loss of or damage to property arising out of my participation in such a trip, including hazards associated with any defect in a manufacturer s product. I, or we, the undersigned, jointly and severally, hereby release and forever discharge ERBA from any and all liability, including negligence (active or passive), as to any right of action or claim to relief that may accrue either to me or my heirs or personal representatives for any such injury, loss of life, or loss of or damage to property which I may suffer while participating in such recreational activity including activities preliminary and subsequent thereto and including any assistance or instruction given by ERBA to me in preparation for such activity and during any tour. I further hold ERBA harmless from any and all liability, actions, causes of actions, dept claims and demands of any kind and nature whatsoever which I now have or may arise from or in connection with my tour or participation in any other activity related thereto. I further understand that ERBA carries no medical insurance for the protection of participants in outdoor activities, and any insurance coverage existing with respect to ERBA shall not alter the terms of this waiver nor impose any liability on ERBA. For purposes of this Release Agreement, ERBA shall include its agents, employees, servants, officers, directors, representatives and any independent contractor providing services through ERBA. I hereby grant ERBA the right to use, for promotional purposes only, any photographs taken by them of me during my participation in this program. I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and I sign it of my own free will. Participant s Signature Print Name Parent or Guardian s Signature (if under 18) Print Name Date Street City State Zip Telephone Address Do you have a medical condition we should be aware of? Would you like to be on our mailing list? (circle one) Yes No Already am How did you hear about us?

Assumption of Risk Sea Kayak Program I understand and accept that outdoor activities such as sea kayaking expose me to many hazards which may occur at locations remote in either time or distance or

6 Assumption of Risk Sea Kayak Program I understand and accept that outdoor activities such as sea kayaking expose me to many hazards which may occur at locations remote in either time or distance or both from health care facilities equipped to handle water sports injuries and physicians trained and experienced to handle such injuries. Some of the dangers and risks which may be present or may include, but are not limited to the following: The hazards of traveling in a kayak in any water conditions. Water hazards including rocks, trees and other obstacles, and fast-moving water. Swimming in unfamiliar and sometimes turbulent water which may be cold. Using paddles, ropes, and other unfamiliar outdoor equipment. Rescue attempts. Injuries inflicted by animals, insects, and plants. Accidents or illness in remote places without medical facilities. Human made objects in the water, including but not limited to ropes, bridge pilings, metal, or junk and other water craft. Carrying kayaks. The forces of nature including lightning, weather changes, water level changes and others not named. The physical exertion associated with paddling and carrying equipment on land. Travel in a vehicle not driven by me. Hypothermia. I acknowledge that the enjoyment and excitement of outdoor activities is derived in part from the inherent risks incurred by this activity beyond the accepted safety of life at home or work. These inherent risks contribute to such enjoyment and excitement and are reason for my participation. I am solely responsible for deciding to participate and continue in this program. I assume all risks and understand my responsibility in decision making. I agree to obey all Essex River Basin Adventure s rules and guidelines. Participant s Signature Printed Name Date Parent or Guardian s Signature (if under 18) Date

CITY OF PALM COAST YOUTH PARKS & RECREATION DEPARTMENT ADULT REGISTRATION FORM SENIOR

CITY OF PALM COAST YOUTH PARKS & RECREATION DEPARTMENT ADULT REGISTRATION FORM SENIOR Please print clearly. Completion of the registration process is required for each participant prior to program start