"*" indicates required fields Camper InfoChild's Name* First Last Child's Date of Birth* MM slash DD slash YYYY Camps(s)Please check the camp(s) that your child is participating in. General Health Construction Culinary STEM Mars Exploration FAA ACE STEM Aviation Robotics Photography Outdoor Recreation Camper Health InfoChild's Doctor* Doctor's Phone*Medical Insurance Carrier* Medical Insurance Policy #* Physical Limitations?*Choose one:YesNoIf yes to physical limitations, please explain.*Current Medications?*Choose one:YesNoIf yes to current medications, please list.*Allergies?*Choose one:YesNoIf yes to allergies, please explain.*Dietary Restrictions?*Choose one:YesNoIf yes to dietary restrictions, please explain.*Waiver InfoParticipation Agreement*I/We acknowledge that my child is enrolled in the MWV School to Career Summer Camp, 2023. My child is in good health and able to participate in the Camp’s activities. Camp organizers will do everything possible to assure that the campers will have a fun, safe and productive experience at the camp. We do need you to understand that the participating agencies and staff of this camp are not responsible for accidents and medical or dental expenses incurred as a result of participation in this program. Accordingly, we ask that parents(s)/guardian(s) complete and sign this waiver. I/We Agree.Release*I/We wish that our child participates in the MWV School to Career Summer Day Camp, which is organized and administered by the Mt. Washington Valley School to Career Partnership. I am familiar with and recognize the risks inherent in the program and I assume all the risks of injury and loss arising or resulting from my child’s participation, hereby releasing and holding harmless all agencies, its employees or agents, from liability for any such injury or loss. I/We Agree.Medical Consent*The medical consent form permits hospital personnel to begin emergency treatment immediately rather than encounter a delay while the adult’s permission is sought. I/we authorize the MWV School to Career Summer Camp staff to carry out standard first aid, including treatment for severe allergic reaction to insect stings, and to arrange for emergency care for my/our minor child at a local hospital, as the staff deems necessary. I authorize hospital personnel to provide emergency medical treatment for my/our child. I/We Agree.Travel Permission*I/We give permission for our child to travel to various sites in the MWV Region by school bus, under supervision of the MWV School to Career Summer Camp staff. I/We Agree.Photo Release*I/We understand that our child/ward may be photographed and/or videoed during participation in the MWV School to Career Summer Camp. The video and photographs will be used for press releases and presentations by program staff. I give my permission for my child to be videoed and/or photographed for promotional and educational purposes only. I/We Agree.Parent/Guardian InfoCommentsPlease feel free to comment on any other information you think would be helpful for us to ensure that your child enjoys the week at camp.Waiver Copy*Would you like an email notification with completed waiver in PDF format?Choose one:YesNoWaiver Copy Email* Enter Email Confirm Email Parent/Guardian 1* First Last Parent/Guardian 1 Signature* Reset signature Signature locked. Reset to sign again Parent/Guardian 1 Signature Date* MM slash DD slash YYYY Parent/Guardian 2 First Last Parent/Guardian 2 Signature Reset signature Signature locked. Reset to sign again Parent/Guardian 2 Signature Date MM slash DD slash YYYY Δ
