Distance Learning Support Program

As part of the registration process, please be advised of the following:
1. Please complete a separate registration form for each child.
2. Be specific and detailed with registration information particularly in the medical section.
3. If your child has special dietary considerations that you would like us to accommodate, please arrange this with Mile High Pines Camp (MHP) in advance; a fee will apply.
4. If you have a child that is in Kindergarten through 2nd grade, please contact us to discuss enrollment before registering; a fee will apply.
5. MHP will not provide medication to students, so please ensure that your student brings what they need.
6. Any absences due to a natural disaster will be refunded.

Primary Contact *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relation to Student *
e.g. parent, grandparent, etc.
Email *
example@example.com
Cell Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number

Add another Contact
Additional Contact

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relation to Student
e.g. parent, grandparent, etc.
Email
example@example.com
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number

My child First Name Last Name has my permission to take the listed medications to Mile High Pines Camp and for certified program staff to assist and/or allow my child to take/apply these medications. Signature Date
Pediatrician's Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

MHP does not supply medication. Participants will only receive medication if it is disclosed on this Medical Form AND it is something that they themselves brought.
Medication Name
e.g. Amoxicillin 500mg
Type of Medication

Over-the-counter Prescription
Dosage
e.g. 1 pill 3x/day, by mouth
When does the medication need to be taken?
e.g. before lunch, as needed, at 9am, etc.
Reason for the medication?
Provide pertinent background info about the medication.
Is there anything else we should know about this medication?

Add another Medication
Medication Name
e.g. Amoxicillin 500mg
Type of Medication

Over-the-counter Prescription
Dosage
e.g. 1 pill 3x/day, by mouth
When does the medication need to be taken?
e.g. before lunch, as needed, at 9am, etc.
Reason for the medication?
Provide pertinent background info about the medication.
Is there anything else we should know about this medication?

Add another Medication
Medication Name
e.g. Amoxicillin 500mg
Type of Medication

Over-the-counter Prescription
Dosage
e.g. 1 pill 3x/day, by mouth
When does the medication need to be taken?
e.g. before lunch, as needed, at 9am, etc.
Reason for the medication?
Provide pertinent background info about the medication.
Is there anything else we should know about this medication?

GENERAL RELEASE WAIVER:
I, First Name*   Last Name*, on behalf of myself and my child, First Name*   Last Name*, have asked Mile High Pines Camp (hereinafter “MHP”) to be allowed to participate in activities offered at MHP. Activities may include but are not limited to: archery, rock climbing, low ropes, gaga ball, contact sports, hiking, zipline, kayaking/canoeing, swimming. The undersigned acknowledges and understands that: (1) MHP activities involve physical exertion and other risks; (2) the possibility of risk of injury to individuals participating in or observing the activities, including but not limited to permanent disability including blindness or death does exist; (3) the need/requirement to participate in the activities in accordance with the rules that are given and to follow directions given by any staff member; (4) it is each participant’s responsibility to wear any and all safety gear deemed necessary by MHP; and (5) a participant’s physical and mental condition will enable him/her to participate safely in the activities. On behalf of myself,First Name*   Last Name*, and my child, First Name*   Last Name*, I hereby waive and release any and all claims, demands, actions, causes of action and rights (contingent, accrued, inchoate, or otherwise), defend, and hold MHP harmless from and against any and all claims, liabilities, expenses, damages, losses, cause of action, and suits (including, without limitation, attorney’s fees and costs) arising out of, or in any way related to, the participation in activities at MHP, whether caused by MHP’s active or passive negligence or otherwise.
Signature*   Date*

IMAGE RELEASE WAIVER:
I, First Name*   Last Name*, on behalf of myself and my child, First Name*   Last Name*, give permission to MHP to use any photographs, video and audio of my child for any promotional materials, including MHP websites and social media postings, without expectation of compensation, including, but not limited to, any royalties, proceeds, and/or other benefits derived from such photographs, videos, or audio recordings.
Signature*   Date*

MEDICAL RELEASE WAIVER:
I, First Name*   Last Name*, on behalf of myself and my child, First Name*   Last Name* give permission to MHP to provide or arrange necessary transportation and to secure and administer proper medical treatment as needed, and give permission to release any records necessary for insurance purposes. They may also give information as necessary to all those who may be in care of my child. MHP first aid personnel, the Director, or proctor may give medication to and/or supervise the administration of medication to your student only if the medication was brought to program by the student to whom it will be administered. I authorize MHP staff to provide care based on their level of training to the program participants indicated on this registration form. I understand that MHP staff might not call parents/guardians before treating or providing care for a sick or injured program participant.
Signature*   Date*

INFECTIOUS & CONTAGIOUS DISEASE WAIVER:
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization (WHO). As a result, federal, state, and local governments and agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. We are doing everything we can to be compliant with all regulations and to ensure participant safety. We have put in place preventative measures to reduce the spread of COVID-19, but we cannot guarantee that your child, you, or your family members will not become infected with COVID-19.

By participating in programs, services, and activities at our facility, I agree to the following:
On behalf of myself, my enrolled child, First Name*   Last Name*, and my family, I, First Name*   Last Name* hereby release, covenant not to sue, discharge, and hold harmless MHP, its employees, agents, and representatives, of and from all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to your participation in our programs, services, or activities. You understand and agree that this release includes any claims based on the actions, omissions, or negligence of MHP, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any MHP-hosted or programmed event.
Signature*   Date*

The CODES’ Distance Learning Support Program (DLSP) at Mile High Pines Camp will provide a supervised, socially distanced learning environment for students in third through twelfth grade (and kindergarten through second grade upon special arrangement). Additionally, the program will provide lunch/snacks daily, and outdoor adventure activities (e.g. hiking, archery, etc.) as a part of our passion for encouraging youth to live “unplugged”.

Please read and review the following with your child; all participants and parents/guardians will be held accountable to the information herein.

On behalf of my enrolled child,   First Name*   Last Name* I, First Name*   Last Name*   understand and agree to the following :
- Appropriate clothing is required at all times; dress for the weather and refrain from wearing anything that may be deemed offensive or divisive. Wear closed-toe shoes daily, no exceptions.
- Come prepared with a laptop, headphones, all necessary school materials and assignments (e.g. paper, notebooks, scissors, glue, etc. ), and dietary supplements (if needed).
- Bring a face mask/shield/covering.
- Cell phones are not permitted. All cell phones found will be confiscated and returned to the parent/guardian at pick up and a warning will be issued. Parents/guardians may contact their child for emergencies by calling the office: (909) 794-2824.
- Participants will use positive language and behavior at all times towards self, others (including virtual classmates, teachers, camp staff), and will respect camp property.
- Participants will participate in all virtual classes and adventure activities as assigned.
- Participants must disclose and submit all medications brought with them to MHP upon arrival, and understand that failure to comply may result in immediate dismissal.
- MHP staff are certified in various levels of first aid and will provide care according to their training.
- MHP will not supply medication for participants. Participants may only take medications that have been supplied by their parent/guardian AND which are disclosed on the participants’ medical form.
- The following are grounds for immediate dismissal from the program:

o  Fighting or stealing

o  Any activity that is inherently dangerous to self or others

o  Outright defiance

o  Intentionally destroying property

o  Other behaviors at the discretion of MHP

- If your child is dismissed from the program prematurely due to illness, injury, or misbehavior. You are required to pick them up immediately.
- You are the liaison between your child and their school and teachers, communicating regularly about assignments, materials, etc.
- Children with special dietary considerations need to supplement their own diet by bringing a lunch/snacks with them.
- Do not send food or snacks that contain peanut butter or nuts. Items must be ready to eat, as warming of foods is not available.
- Lunch is not provided for those enrolled in Half Days.
- Program times are 7:30am-12pm (Half Day) or 7:30am-5:30pm (Full Day). Contact MHP promptly if your child needs to be dropped off or picked up outside of these times; a fee will apply.
- Any absence that is due to a natural disaster, will be refunded.
- Payment for the following week is due on Friday by EOD.
- Participants will be assigned to learning pods and will remain in these pods for the duration of their enrollment. Participants may not switch learning pods from week to week.
Signature*   Date*

In which pod would you like to enroll your child? *

Full Week, Full Day: 5 days/wk from 7:30am-5:30pm, $145.00 Full Week, Half Day: 5 days/wk from 7:30am-12:00pm, $95.00 Hybrid Week, Full Day: 3 days/wk from 7:30am-5:30pm, $90.00 Hybrid Week, Half Day: 3 days/wk from 7:30am-12:00pm, $60.00
Should be Empty: