Child Registration Form, Mohr's Explorers, LLC, 2021-22

The purpose of this form is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under the authority of Mohr’s Explorers, LLC. It is the firm hope the authorization granted by this form will never need to be used. However, to insure the safety of the children in an emergency situation where the parent or guardian cannot be immediately contacted, this form may become extremely important. This form grants parental permission for all programming provided by Mohr's Explorers, LLC throughout the 2022-23 school year and is valid for the entire school year.

Please Register My Child For The Following (check any that apply)*

Mohr's Explorers Outdoor After-School Program (New York/Central Park)Mohr's Explorers Outdoor After-School Program (New Jersey/South Mountain Reservation)

Please List Your Preferred Day Of The Week (if applicable)*

Please note: each day is not guaranteed to run, so be sure to list at least one alternative option, if applicable. *** If this is for a Mini-Camp or summer, list the week(s) you wish to attend. ***

Please List Preferred Time Frame (with at least one 2nd choice)*

Time frame options for NYC are 1:15-3:00 p.m. or 3:30-5:15 p.m. Please note: each time frame is not guaranteed to run, so be sure to list at least one alternative option. *** If this is for summer, the time frames are either 8:30 a.m.-12:30 p.m. or 1:00-5:00 p.m. ***

Please List Preferred Time Frame (with at least one 2nd choice)*

Time frame options for NJ are 1:45-3:30 p.m. or 3:45-5:30 p.m. Please note: each time frame is not guaranteed to run, so be sure to list at least one alternative option. *** If this is for summer, the time frames are either 9:00 a.m.-1:00 p.m. or 1:30-5:30 p.m. ***

Please List Preferred Location (with at least one 2nd choice)*

E. 79th, W. 81st, W. 93rd or W. 108th Streets. Please note: each location is not guaranteed to run, so be sure to list at least one alternative option.

Child's Full Name*

First Name Last Name

Date of Birth*

mm/dd/yyyy

Age*

Grade*

Pre-K, K, 1st, 2nd, 3rd, etc.

Gender*

School Name*

Home Address*

Street Address

Apartment, Suite, Unit, etc. (optional)

City State

Zip Code

T-shirt Size (in case it's necessary!)*

Youth Small (6/8)Youth Medium (10/12)Youth Large (14/16)

I permit my child’s name to be published on the password-protected Hall of Fame portion of www.mohrs-explorers.com when/if applicable.*

YesNo

I give Mohr’s Explorers, LLC permission to reproduce and publish any photograph of my child for advertising, commercial or any lawful purpose.*

YesNo

EMERGENCY INFORMATION

List the full names and complete contact information of each adult who has the authority to make decisions in an emergency situation involving this child. List each adult in the order in which you want contact attempts to be made and please include at least one parent or legal guardian.

1. Parent/Guardian Full Name*

First Name Last Name

Relationship to Child*

Mom, Dad, Guardian, etc.

Cell Phone*

Home Phone

Work Phone

Preferred e-mail Address*

example@example.com

Add to the Mohr’s Explorers e-mail List?*

YesAlready on ListNo (if you are already on the list, you will removed by checking here)

2. Parent/Guardian Full Name

First Name Last Name

Relationship to Child

Mom, Dad, Guardian, etc. * Required if listing an additional emergency contact.

Cell Phone

* Required if listing an additional emergency contact.

Home Phone

Work Phone

Preferred e-mail Address

example@example.com * Required if listing an additional emergency contact.

Add to the Mohr’s Explorers e-mail List?

YesAlready on ListNo (if you are already on the list, you will removed by checking here)

3. Parent/Guardian Full Name

First Name Last Name

Relationship to Child

Mom, Dad, Guardian, etc. * Required if listing an additional emergency contact.

Cell Phone

* Required if listing an additional emergency contact.

Home Phone

Work Phone

Preferred e-mail Address

example@example.com * Required if listing an additional emergency contact.

Add to the Mohr’s Explorers e-mail List?

YesAlready on ListNo (if you are already on the list, you will removed by checking here)

Additional Parent(s)/Guardian(s)

If applicable, please include full names, relationship to child, preferred cell phone numbers and e-mail addresses for each additional person you wish to list.

MEDICAL INFORMATION

Please let us know of any medical conditions (allergies/asthma/etc.) we should be aware of. If you would like us to carry an Epi-Pen, inhaler, etc., please explain all of the details below.

Child's Physician*

Physician's Phone*

Child's Dentist*

Dentist's Phone*

Date of Last Tetanus Shot

If you do not remember, you may e-mail it later.

Medical Conditions (if applicable)*

If there are none, please type "none."

If your child requires any medications to be administered by us, please include a list of specific instructions (dosage, times/day, times of day it needs to be taken, etc.), including the name(s) of the medication(s) and what the medication(s) is/are specifically prescribed for. You may also e-mail it separately, if you do not have it handy.

Detailed Medication Instructions (if applicable)*

If you typed none above, please type "none" here as well. If planning to e-mail separately, please note that here.

OTHER INFORMATION

Please include any pertinent information that may be helpful to know about your child, whether that be medical, behavioral or otherwise. We appreciate any notes you feel are necessary and if you have any strategies that may be necessary, you cannot give us too many details!

Additional Notes About Your Child*

Nothing to report? Please type "nothing."

PARENTAL PERMISSION, RELEASE OF LIABILITY, WAIVER, AND ASSUMPTION OF RISKS

Mohr’s Explorers, LLC has my permission for my child (enter child's full name below)

Child's Full Name*

First Name Last Name

to participate in the Outdoor After-School Program, Mini-Camps, the Summer EDventure Camp and/or any other programming options for the 2022-23 school year, including Camping Trips if/when we decide to bring them back again. I hereby consent to all included activities planned and supervised by Mohr’s Explorers, LLC and I hereby consent to all methods of travel necessary to reach various destinations (only when applicable) throughout Manhattan, Queens, Brooklyn, the Bronx, Staten Island, upstate New York, New Jersey, Pennsylvania and other areas, whether it be via subway, train, bus, van, tram, taxi, Uber, etc. However, I understand that if any COVID-19 related restrictions are in place, there may be no travel options. I also give my permission to Mohr’s Explorers, LLC to treat my child for routine, minor injuries, such as cuts, scrapes and bruises. In the event that my preferred contacts listed above cannot be reached in an emergency, I hereby grant Mohr’s Explorers, LLC permission to bring my child to be treated at a hospital emergency room. In the event of illness or injury, I do hereby consent to any treatment and hospital care, that are considered necessary in the best judgment of the attending physician, surgeon and/or dentist, and the undersigned agrees that his/her health insurance will be used as the primary coverage, if necessary, to cover such medical care.

In consideration of Mohr’s Explorers, LLC accepting this registration and permitting the participation of the above named child in such activities, which I believe to be educational and/or physical, I, on behalf of myself, my spouse, children, heirs, personal representatives, next of kin, successors, administrators and assigns, hereby release, discharge, indemnify, hold harmless and defend Mohr’s Explorers, LLC, its employees, agents, representatives and consultants, as well as all other persons, corporations, or other entities that might have any liability to me (the “Released Parties”), from and against, specifically including, but not limited to, any and all damages, claims, demands, losses, actions, liabilities and expenses of any nature, including costs and attorney's fees, whether known or unknown, anticipated or unanticipated, suspected or unsuspected, relating to, arising out of or in connection with the above named child’s participation in any aspect of the activities provided by or involving Mohr's Explorers, LLC, occurrence or event sponsored by or involving Mohr's Explorers, LLC or caused by the passive or active negligence of the Released Parties. This Release is intended to release and discharge the Released Parties from all damages, actions, claims and liabilities of any nature, specifically including, but not limited to, damages, actions, claims and liabilities arising from or related to the negligence of the Released Parties.

I HEREBY VOLUNTARILY WAIVE ANY RIGHT I MAY HAVE TO A TRIAL BY JURY IN ANY ACTION, PROCEEDING, OR LITIGATION INVOLVING ANY RELEASED PARTY.

THIS RELEASE IS A BINDING LEGAL CONTRACT BETWEEN MOHR'S EXPLORERS, LLC AND MYSELF. PLEASE READ IT CAREFULLY BEFORE SIGNING.

I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS.

Full Name of Undersigned Parent/Guardian*

First Name Last Name

Electronic Signature of Parent/Guardian*

Clear

By signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current e-mail address in order to contact you regarding any changes, if necessary.

To be read and signed by both the participating child and parent/guardian.

All members of Mohr's Explorers have an important role to play in keeping our community safe by doing our part to stop the spread of COVID-19. As a member of the Mohr's Explorers family, we (participants and parents/guardians) know that we must take steps to stay well in order to protect others. Because of this, we pledge to take responsibility for our own health and help stop the spread of the COVID-19.

Mohr's Explorers' highest priority is the safety of its participants, staff, everyone's families and other visitors of Central Park. We know that despite all of our precautions, we may be exposed to COVID-19 and other infections. We also understand that despite all reasonable efforts by Mohr's Explorers, we can still contract COVID-19 and other infections. In order to reduce our risk, we agree to be an active participant in maintaining our own health, well-being and safety, as well as the safety of others, by following all the guidelines and expectations outlined by Mohr's Explorers.

As more information is gathered and known, we understand that Mohr's Explorers may modify these guidelines and expectations. It is our responsibility to make every effort to keep ourselves apprised of these changes to protect ourselves and the Mohr's Explorers community.

It is our Explorer Pledge to protect ourselves, our peers and our community by doing the following:

Agree to testing for COVID-19 and potential subsequent self-quarantining if we are identified as a contact of anyone who has been determined to be positive for COVID-19.
If we think or know we had COVID-19 and we had symptoms, we agree to self-quarantine in a designated location until:
- It has been at least 10 days since the start of our symptoms and
- 24 hours with no fever without the use of fever-reducing medications and
- Other symptoms of COVID-19 are improving. *
  * Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation.
  - Please note that most people do not require testing to decide when they can be around others; however, if your healthcare provider recommends testing, they will let you know when you can resume being around others based on your test results.
If we tested positive for COVID-19 but had no symptoms, we agree to self-quarantine in a designated location until:
- 10 days have passed since we had a positive viral test for COVID-19.
  - Please note that most people do not require testing to decide when they can be around others; however, if your healthcare provider recommends testing, they will let you know when you can resume being around others based on your test results.
  - If you develop symptoms after testing positive, follow the guidance above for “We think or know we had COVID-19 and we had symptoms.”
If we have had close contact with someone with COVID-19, we agree to self-quarantine in a designated location until:
- It has been at least 14 days after our last exposure to that person.
  - However, please note that anyone who has had close contact with someone with COVID-19 does not need to stay home as long as they meet each of the criteria below:
    - developed COVID-19 illness within the previous 3 months and
    - has recovered and
    - remains without COVID-19 symptoms (for example, cough, shortness of breath).
Timely report any known or potential exposures to COVID-19 to Mohr's Explorers.
Monitor for the following symptoms:
- A fever of 100.4°F or higher
- Respiratory symptoms, such as dry cough or shortness of breath
- Sore throat
- Fatigue
- Headache
- Body or muscle aches
- Chills and/or repeating shaking with chills
- New loss of taste or smell
- Congestion or running nose
- Nausea or vomiting
- Diarrhea
- There are many sources available, but please note that up-to-date symptoms can be found at: https://wexnermedical.osu.edu/features/coronavirus/patient-care/symptoms-and-prevention
If we develop the above symptoms, to contact our doctor, and to follow the medical staff’s instructions which may include being tested for COVID-19 and self-quarantining while the test results are pending, and/or being evaluated by our doctor.
Stay at home if we are feeling sick.
Participate fully and honestly with Mohr's Explorers for contact tracing to determine whom we might have potentially exposed to COVID-19.
Wear a mask or acceptable face covering when Mohr's Explorers staff requires.
Practice physical distancing as much as possible and respect each other's personal space.
Frequently wash and/or sanitize our hands.
Keep our hands to ourselves (including shaking or holding hands, high-fives, hugs, etc.) and do not touch anyone else's personal belongings.
Leave all personal items at home, such as cards, games, balls, toys, books, electronics, etc.

We understand COVID-19 is a highly contagious virus and it is possible to develop and contract the COVID-19 disease, even if we follow all of the safety precautions above and those recommended by the CDC, local health department, and others. We understand that although Mohr's Explorers is following the coronavirus guidelines issued by the CDC and other experts to reduce the spread of infection, we can never be completely shielded from all risk of illness caused by COVID-19 or other infections.

We have read, understand, and agree to comply with our Explorer Pledge above. We also acknowledge that these expectations and pledge are a condition of our participation in Mohr's Explorers and that any failure to comply with our Explorer Pledge above may lead to immediate removal from the program.

We take our Explorer Pledge seriously and will do our part to protect all within the Mohr's Explorers family so that we can get outside for a little while and have some fun!

Full Name of Undersigned Child*

First Name Last Name

Electronic Signature of Participating Child*

Parents can fill this in, but we would like for the kids to understand our mission and be a part of it, so please go through this with them -- thanks! Clear

Full Name of Undersigned Parent/Guardian*

First Name Last Name

Electronic Signature of Parent/Guardian*

Clear

By signing here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By signing here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current e-mail address in order to contact you regarding any changes, if necessary.

CHILD REGISTRATION FORM

ACKNOWLEDGEMENT AND PLEDGE