Summer Camp Detailed Registration Form

Summer Camp Sessions. Monday, Tuesday and Thursday 9am-3pm Wednesday time varies but most times are between 1pm-4pm.

Adult in Training (AIT) Information

Adult in Training's Name

First NameLast Name

Adult in Training's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date

MonthDayYear

Gender

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Guardian Information

Name

First NameLast Name

Home Number

Format: (000) 000-0000.

Cell Number

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the adult in training have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the adult in training prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Off to a Great Start! during the selected camp. In exchange for the acceptance of said AIT’s candidacy by Off to a Great Start!, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Off to a Great Start! . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said AIT, I hereby waive all claims against Off to a Great Start! . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization As Guardian of the named AIT, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Off to a Great Start!. and its affiliates including Director and support staff to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Participation Behavior: Client and Parent understand that at any time behavior is unacceptable in a workplace (violence towards others or property), spitting at others, throwing items and furniture, or any other actions that could lead to harm to self or others the client may be asked to leave without refund. The Client and Parents also understand that clients participate at their own free will and parents will be informed when clients participation decreases or is of concern of not meeting agreed upon goals set. Clients may be asked to leave for the day if at any time they are unable to work with Off to a Great Start! Staff in a positive manner.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Adult in Training Signature

Guardian Signature

Transportation Consent

During the Off to a Great Start! program transportation to and from activities will be provided by Off to a Great Start! Staff. Vehicles include a Buick Enclave and Nissan Sentra both with full coverage insurance.

By signing this form you give consent for your child to ride in the above-listed vehicles during the program.

Adult in Training Signature

Guardian Signature

Payment

Once I have recieved your registration I will send you an electronic invoice through Square.

Adults in Training Summer Camp Registration