Breckenridge Mountain Camp. Camper Information Packet

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Breckenridge Mountain Camp Camper Information Packet 2015-2016 Please complete this packet and the Emergency Medical Information card.

1 Breckenridge Mountain Camp Camper Information Packet Please complete this packet and the Emergency Medical Information card. The accuracy of the information provided is vital in an emergency situation. Your child may not attend any Colorado State Licensed youth program if this information is absent. Packet is valid through May 31, 2016 Immunization Records are required for all new participants. Please completed packet to fax to or turn into Rec Center Front Desk.

2 February 22, 2015 Dear Breckenridge Mountain Camp (BMC) Parents! Welcome back for what is shaping up to be an extremely exciting summer at the BMC Summer Day Camp! We have been working hard this winter preparing fun summer activities for your child(ren)! We have again, been able to keep the camper packet short for easy registration! The information in this packet will help ensure that your child has a fun and safe time at BMC. Please be sure to pick up a 2015 Parent/Camper Handbook so you and your child will fully understand the guidelines and expectations for camp. The Handbook will also answer most of your questions regarding BMC! Now for a little glimpse into the summer! Please read below for new BMC information: Changes & Reminders for 2015 We now offer Saturday BMC Camp held at the Ice Arena all summer! Fees for Monday-Friday Camp days are $38 (Breckenridge resident child) and $43 (non-resident child). The fee is the same for Wednesday field trip days. Refunds will ONLY be credited to your child s Active account. Credit card, cash or check refunds will not be available. Credits may be used indefinitely for future camp days or other Recreation Department programs and activities. A Recreation Aide is available for campers with special needs. Should a child require accommodations or personalized attention, parents must contact the Youth Coordinator four weeks prior to attending camp to arrange an informational meeting with the Aide and to request camp dates he or she would like to attend. BMC s Character Building Incentive teaches campers Respect, Sportsmanship and Responsibility. They will have the opportunity to earn rewards and recognition through this program. As a reminder, all cancellations for camp and lunch need to be made by 7:15 AM the morning of the cancellation in order to receive a refund on your child s Active account. A $3 cancellation fee will apply. When cancelling, parents must specify that the items cancelled (Camp & Lunch) in order to be refunded. Please note registrations will not be accepted without a complete Camper Packet and copy of immunizations for each child. Registrations cannot to be made until this paperwork is submitted and reviewed by the front desk staff. In the spirit of camping, Jessica Morse, Youth Coordinator jessm@townofbreckenridge.com 2

3 EMERGENCY/MEDICAL CARD Child s Name: Birth : / / Age: School: _ Grade (Sept. 2014): Mailing Address: Physical Address: Parent/Guardian 1 Name: Employer: Work Phone: Cell Phone: Cell Phone Provider Parent/Guardian 2 Name: Employer: Work Phone: Cell Phone: Cell Phone Provider We will contact parents via text message in case of Emergency. In order for the text to go through we need your provider. If you do not wish to provide us with this information you are agreeing not to be contacting in case of Emergency. Emergency Contacts: Person, other than parent, to be notified in an emergency when parent is not available: Name: Relationship:_ Phone: Name: Relationship:_ Phone: Person(s) other than parent to whom the child may be released in emergency: Name: Relationship:_ Phone: Name: Relationship:_ Phone: Does your child have any health problems (chronic or disabling medical or social problems, i.e., seizures, asthma, diabetes, allergies, heart disease, respiratory problems, hearing impairment, internal tubes, etc.)? Yes: No: If yes, explain: Does your child need accommodations because of a disability in order to participate in BMC? Y N If yes, are you interested in having a Recreation Aide assist your child during camp? Y N Please list any allergies your child may have (If none, state NONE ): Child s Physician: Address: Phone: 3

4 Child s Dentist: Address: Phone: _ Hospital of Choice: Medication Authorization The Town of Breckenridge cannot administer prescription medication to a child participating in the Breckenridge Mountain Camp program without the written order of a person with prescriptive authority and with written parental consent. If you want your child to receive prescribed medication while participating in the Breckenridge Mountain Camp program, you must sign this form and return it, along with a copy of the prescription, to the Breckenridge Mountain Camp. No medication will be administered without signed authorization. Please contact Jess Morse if medication is needed, to ensure the necessary forms are completed. 1. My child is currently NOT on any medications: Parent/Guardian Signature 2. I hereby give my permission for the certified personnel of the Breckenridge Mountain Camp to administer the prescribed medication(s) to my child as set forth below. Name of Child: Prescribed medication(s) to be given to child: Specific dosages and time(s) when medication is to be given: Medication(s) prescribed by doctor : Practitioner Name: Practitioner Telephone: Name of Medication: Medication Duration: _ Reason for Medication (unless confidential): Side effects or possible reactions: _ Special directions: Physicians Signature Parent/Guardian Signature *If you said yes to number 2, Please call Jess Morse at prior to turning in packet* Sunscreen Guidelines I acknowledge that I have reviewed the BMC Sunscreen Guidelines and give authorization to staff to administer sunscreen during the course of the camp program as needed. I also acknowledge that my child does not have any known allergies to Rocky Mountain Sunscreen. Parent/Guardian Name (Print): Parent/Guardian (Signature): _ : FOR MEDICAL REASONS, DO NOT APPLY SUNSCREEN TO MY CHILD UNDER ANY CIRCUMSTANCES. I understand that it is my responsibility to provide sunscreen for my child. Statement of Authorization I,, hereby give my permission to the Town of Breckenridge to call a Print Parent/Guardian Name doctor or dentist for medical, surgical or dental care for my child should an Print Child s Name 4

5 emergency arise. It is understood that conscientious efforts will be made to locate me, or the emergency contact name(s) listed on this Emergency/Medical Card before any action will be taken. If I or the contact(s) cannot be located, I assume financial responsibility for such care. Parent/Guardian Signature Immunization Verification I,, verify that my child s Immunization Card, which is on file with the Breckenridge Print Parent Name Mountain Camp, is still accurate and all immunizations remain current. Parent/Guardian Signature Photography & Video Release I acknowledge that I have reviewed the Town of Breckenridge s Video & Photography release, and I allow my child to take part in promotional materials for the Town of Breckenridge. Name of Child: Address: Signature of Parent/Guardian: _ : I DO NOT WANT MY CHILD TO BE PHOTOGRAPHED. Bus Information Acknowledgement I am aware that campers will be riding regularly on the Recreation Department 15-Passenger Vans and Mini Buses. These Mini Buses may not all include seatbelts. Campers will also be using the FREE Ride and Summit Stage public bus systems and Eagle County School District Buses for field trip transportation. I,, understand that seat belts may not be available on vehicles used by Breckenridge Print Parent/Guardian Name Mountain Camp. Parent/Guardian Signature I acknowledge that I have reviewed, understand and agree to: (Please check or initial each shaded box.) Registration, Cancellation & Transfer Policy (Page 8-10 of 2015 Parent/Camper Handbook) Discipline Guidelines (Page 11 of 2015 Parent/Camper Handbook) Field Trip Authorization (Page 12 of 2015 Parent/Camper Handbook) 5

BRECKENRIDGE RECREATION CENTER WAIVER OF LIABILITY FORM Each part of this form must be 880 Airport Road completed to gain admittance Breckenridge, CO 80424 to the ROCK CLIMBING WALL RECREATION CENTER

6 BRECKENRIDGE RECREATION CENTER WAIVER OF LIABILITY FORM Each part of this form must be 880 Airport Road completed to gain admittance Breckenridge, CO to the ROCK CLIMBING WALL RECREATION CENTER - CLIMBING WALL PART 1. RELEASE/INDEMNIFICATION OF ALL CLAIMS AND COVENANT NOT TO SUE (Initial each) 1. NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. By signing this agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any injury to yourself or your property or for your death however caused arising out of your use of the facilities of the Breckenridge Recreation Center, now or any time in the future. 2. I HEREBY ACKNOWLEDGE AND AGREE that the sport of rock climbing and the use of the facilities of the Town of Breckenridge Recreation Center Climbing Wall (hereinafter referred to as the Wall), its climbing wall and other training facilities, has inherent risks. I have full knowledge of the nature and extent of all the risks associated with rock climbing and the use of the Wall, including but not limited to: 1. All manner of injury resulting from falling off the climbing wall and hitting rock faces and projections, whether permanently or temporarily in place, or the floor; 2. Rope abrasion, entanglement and other injuries resulting from activities on or near the climbing wall such as, but not limited to, climbing, belaying, rappelling, lowering on rope, rescue systems, and any other rope techniques; 3. Injuries resulting from falling climbers or dropped items, such as, but not limited to, ropes or climbing hardware; 4. Cuts, abrasions, contusions, dislocations, torn muscles and/ or ligaments, and fractured or broken bones resulting from contact with 5. the climbing wall or climbing area floor; 6. Failure of ropes, slings, harnesses, climbing hardware, anchor points, or any part of the climbing wall structure. I further acknowledge that the above list is not inclusive of all possible risks associated with the use of the Wall and that the above list in no way limits the extent or reach of this release and covenant not to use. 3. RELEASE/INDEMNIFICATION AND COVENANT NOT TO SUE. In consideration of my use of the Wall, I, the undersigned user, agree to release and on behalf of myself, my heirs, representatives, executors, administrators and assigns, HEREBY DO RELEASE the Town of Breckenridge, its officers, agents, sponsors and employees from any cause of action, claims or demands of any nature whatsoever, including but not limited to, a claims of NEGLIGENCE, which I, my heirs, representatives, executors, administrators and assigns may now have, or have in the future against the Wall on account of personal injury, property damage, death or accident of any kind, arising out of, or in any way related to my use of the Wall whether that use is supervised or unsupervised, however the injury or damage is caused, including, but not limited to, the NEGLIGENCE of the Town of Breckenridge, its officers, agents, and employees. In consideration of my use of the Wall, I, the undersigned user, agree to INDEMNIFY AND HOLD HARMLESS the Town of Breckenridge, its officers, agents and employees from any and all causes of action, claims, demands, losses, or costs of any nature whatever arising out of or in any way relating to my use of the Wall. I hereby certify that I have full knowledge of the nature and extent of the risks inherent in the use of the Wall and that I am voluntarily assuming the risks. I understand that I will be solely responsible for any loss or damage, including death, I sustain while using the Recreation Center and that by this agreement, I am relieving the Town of Breckenridge of any and all liability for such loss, damage or death. I further certify that I am in good health and that I have no physical limitations which would preclude my safe use of the facilities. I further certify that I am of lawful age (18 years or older) and otherwise legally competent to sign this agreement. I further understand that the terms of this agreement are legally binding and I certify that I am signing this agreement, after having carefully read it, of my own free will. If under the age of 18, this release must be signed by the parent/ guardian of the minor gaining access to the climbing wall. IN WITNESS WHEREOF, this instrument is duly executed at Breckenridge, Colorado, on. Today s date User s Signature User s Name PRINTED CLEARLY of Birth Address City State Zip Phone Number I, as parent or guardian of the above minor under 18 years of age, hereby consent to the terms and conditions set forth in this Release Form. Parent/Guardian if User is under 18 years of age *WAIVER CONTIUED ON BACK Printed Name

7 PART 2. CONTRACT TO FOLLOW SAFETY POLICIES OF CLIMBING WALL The Town of Breckenridge reserves the right to deny access to its facilities to any individual permanently or for a specified period of time for breach of contract in the following Safety Policies, or for any conduct that is viewed as unsafe or inappropriate. I, the undersigned user of Breckenridge Recreation Center Climbing Wall, accept full responsibility for my own safety and the safety of other climbers while on the premises of Breckenridge Recreation Center. I agree to abide by, and to help enforce, the following Safety Policies: 1. All users must have a signed Waiver of Liability Form on file and be certified to climb by the climbing wall staff. 2. All users must pass a skills check yearly or be accompanied by an instructor to use the wall. 3. An adult must accompany users under the age of Use of a helmet is recommended. Helmets are available through the climbing wall staff. 5. Bouldering allowed only to the designated heights. 6. All personal equipment must be used in accordance with manufacturer instructions. All users must acknowledge, assume and accept ALL responsibility for the proper selection, use, care, maintenance, inspection and storage of any personal climbing equipment. 7. Use proper climbing commands before each climb. 8. No horseplay allowed in the climbing wall areas. 9. No food or drink allowed in the climbing wall areas. 10. Please inform staff of any unsafe situation or violation of safety policy. All accidents or equipment damage must be reported. 11. Climb at your own risk. In consideration of the use of the Wall, I acknowledge that I have read and agree to abide by the Safety Policies. User s Signature/Parent or Guardian Signature (required): Checklist for bouldering/top rope belay Waiver signed: Demonstrating proper spotting: Demonstrating proper falling: Review of wall rules: Harness double-backed and proper fit: Proper tie in using Figure 8 knot: Correct side of rope used: Proper belay technique used: Climbing commands used: Able to catch fall: Proper lowering: Review of Auto Belay: F O R E M P L O Y E E U S E O N L Y Checklist for lead climbing All Top Rope points checked: Proper belay technique: Spotting before first clip: Rope management: Able to catch a fall: Review of backclipping: Review of z-clipping: Correct clipping: Rope awareness: Take a fall: PASS FAIL notes: has successfully completed the skills check and has demonstrated proficiency in the above checked areas. Tested By: : Skills check type entered into computer: BLDR TRCLM LDCLM Staff Initials:

8 PARENTAL RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT (PARTICIPANTMUST READ CAREFULLY BEFORE SIGNING!) As used in this agreement, the term Town means the Town of Breckenridge, Colorado. The term Program means the following Breckenridge Mountain Camp program run by the Town s Recreation Department:. The term My Child means: _, whose date of birth is:. I want My Child to participate in the Program, and in return for the Town permitting My Child to participate in the Program I acknowledge, represent, and agree with the Town as follows. I am aware that the Program may be dangerous, and can involve the risk of injury, loss, or damage, including bodily injury, personal injury, sickness, disease, death, and property loss or damage. I acknowledge that such risks may arise from a variety of foreseeable and unforeseeable circumstances. I have been advised by the Town of the following specific risks associated with My Child s participation in the Program: BRECKENRIDGE MOUNTAIN CAMP PROGRAM PARTICIPATION INVOLVES BEING PHYSICALLY ACTIVE IN A DYNAMIC ENVIRONMENT THAT CANNOT BE CONTROLLED. THIS ENVIRONMENT INCLUDES BOTH INDOOR AND OUTDOOR SETTINGS, WHICH MAY BE LOCATED AT THE BRECKENRIDGE RECREATION CENTER OR OTHER DESIGNATED OFF-SITE LOCATIONS. THE ENVIRONMENT INCLUDES EXPOSURE TO VARIABLE WEATHER CONDITIONS, SUN, RAIN, VARIABLE TERRAIN, TOYS, PLAY STRUCTURES, ARTS & CRAFTS SUPPLIES, SPORTS EQUIPMENT, GENERAL FACILITY EQUIPMENT, AND ITEMS WITH MOVING PARTS AND PIECES. EQUIPMENT FAILURE MAY OCCUR WHILE A PARTICIPANT IS PARTICIPATING IN THE PROGRAM. CHILDREN ARE SUBJECT TO THE ACTIONS OF OTHER CHILDREN WHOSE BEHAVIOR IS UNPREDICTABLE. IN ADDITION, CHILDREN WILL BE EXPOSED TO NON PROGRAM PARTICIPANTS, PARTICULARLY WHILE OFF SITE ATTENDING FIELD TRIPS. THESE HAZARDS CAN CAUSE CUTS, ABRASIONS, CONTUSIONS, DISLOCATIONS, TORN MUSCLES AND/OR LIGAMENTS, FRACTURES, HEAD INJURIES, SPINE INJURIES, OTHER TYPES OF INJURIES, OR EVEN DEATH. PARTICIPATION IN STRENUOUS ACTIVITIES AT SUMMIT COUNTY S HIGH ALTITUDE ALSO POSES HEALTH RISKS, INCLUDING, BUT NOT LIMITED TO, BREATHING AND CARDIAC DIFFICULTIES. PARTICIPATION INVOLVES BEING TRANSPORTED IN A SUMMIT SCHOOL DISTRICT VEHICLE, SUMMIT STAGE VEHICLE AND/OR TOWN OWNED VEHICLE OPERATED BY TOWN STAFF FROM BRECKENRIDGE, COLORADO TO A VARIETY OF LOCATIONS THROUGHOUT COLORADO. I represent to the Town My child is in good physical condition with no known MEDICAL CONDITION OR PROBLEM that could limit his or her ability to safely participate in the Program. I agree that the Town, its officers, employees, insurers, and self-insurance pool (called the "Released Parties" in this remainder of this agreement) are NOT RESPONSIBLE for My Child s safety in connection with My Child s participation in the Program. I specifically RELEASE and DISCHARGE the Released Parties in advance from any and all liability in connection with My Child s participation in the Program, even though such liability may arise out of the act, omission, negligence, carelessness, or other fault of the Released Parties, or from any other cause.

9 I ACCEPT AND ASSUME FULL RESPONSIBILITY FOR THE RISKS, conditions and hazards which may arise or occur during my participation in the Program, whether they are known or unknown at the time I sign this agreement. Being fully aware of the disclosed risks, conditions, and hazards of the Program, and that certain risks, conditions, and hazards associated with the Program may be unknown to me when I sign this agreement, I HEREBY AGREE TO WAIVE, RELEASE AND DISCHARGE the Released Parties in advance from all liability for claims for bodily injury, personal injury, sickness, disease, death, and property loss or damage which may accrue to My Child or me after signing this agreement as a result of My Child s participation in the Program, whether such injury, loss or damage was foreseeable or not, or was caused by the act, omission, negligence, carelessness, or other fault of the Released Parties, or from any other cause. This waiver includes any claim resulting from the design or condition of any Town-owned or supplied equipment utilized by My Child in the Program. I agree to HOLD HARMLESS, INDEMNIFY AND DEFEND the Released Parties from any and all liability for bodily injury, personal injury, sickness, disease, death, and property loss or damage legally arising from or caused by My Child s participation in the Program, even though such liability may arise out of the act, omission, negligence, carelessness, or other fault of the Town, its officers or employees, or from any other cause. I agree with the Town that this agreement is to be interpreted as waiving and releasing all claims arising from My Child s participation in the Program EVEN THOUGH CAUSED BY THE ACTS, OMISSIONS, NEGLIGENCE, OR THE FAULT OF THE RELEASED PARTIES. This agreement is intended to be AS BROAD AND INCLUSIVE as is permitted by the laws of the State of Colorado. If any portion of this agreement is found to be invalid, the balance of this agreement shall continue in full force and effect. This agreement shall be governed by the laws of the State of Colorado, and any lawsuit or claim involving My Child s participation in the Program or this agreement shall be brought only in the state courts of Summit County, Colorado. I will accept and abide by all of the RULES AND REGULATIONS of the Town in connection with My Child s participation in the Program, and I understand that My Child may loose the privilege of participating in the Program if he or she fails to abide by all of the Program Rules and Regulations. This agreement is effective as of the date set forth below and is binding upon me, my heirs, executors, personal representative, successors and assigns. SIGNATURE OF PARENT/GUARDIAN: DATE: In accordance with (4) of the Colorado Revised Statutes, this agreement shall not be construed to permit a parent acting on behalf of his or her child to waive the child s prospective claims against the Town, its officers and employees, for a willful and wanton act or omission, a reckless act or omission, or a grossly negligent act or omission.

After School Program Registration Form

2018-19 After School Program Registration Form Office Use Only Date registered: _ Staff: Please fill out this form entirely. If there are blanks it may slow down your child s enrollment process. If a line