Child Registration Form, Mohr's Explorers, LLC, 2023-24

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 2023-24 school year and is valid for the entire school year, from the beginning of the fall through the end of the summer.

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)Other

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

Please note: Open Groups are not guaranteed to run each day. Please list at least one alternative day, if applicable. *** If this is for a Mini-Camp, Camping Trip or the summer, list the day(s) and/or 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 NameLast Name

Date of Birth*

mm/dd/yyyy

Age*

Grade*

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

Gender*

School Name*

Teacher Name/Classroom Number

We only need this for kids from MSC or the South Mountain School. If you do not yet know, please e-mail this information as soon as you have it.

Home Address*

Street Address

Apartment, Suite, Unit, etc. (optional)

CityState

Zip Code

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

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

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 NameLast 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 List (if not, please add me)No (if you are already on the list, you will removed by checking here)

2. Parent/Guardian Full Name

First NameLast 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 List (if not, please add me)No (if you are already on the list, you will removed by checking here)

3. Parent/Guardian Full Name

First NameLast 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 List (if not, please add me)No (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."

This is generally only for overnight trips, but 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

I hereby give permission for my child (enter child's full name below)

Child's Full Name*

First NameLast Name

to participate in the following outdoor programs offered by Mohr’s Explorers, LLC during the 2023-24 school year (understood to be from the fall of 2023 through the end of the summer of 2024):

After-School Program
Overnight Camping Trips
Summer EDventure Camp
Birthday Parties
Mini-Camps
Any other programming options that may be introduced

I hereby consent to all included activities planned and supervised by Mohr’s Explorers, LLC, I understand that Mohr's Explorers is an outdoor program and takes place outdoors in all types of weather, and I hereby consent to any mode of transportation deemed necessary by Mohr's Explorers, LLC for travel within Manhattan, Queens, Brooklyn, the Bronx, Staten Island, New York State, New Jersey, Pennsylvania and other areas. Modes of transport may include, but are not limited to, subway, train, bus, van, tram, taxi, Uber, ferry, boat, etc.

I also grant permission to Mohr’s Explorers, LLC staff to treat my child and administer first aid for injuries, such as scratches, cuts, scrapes, bruises, strains, sprains, insect bites and stings, animal bites, fractures, etc. In the event that my preferred emergency 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 NameLast 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