Information about Participant
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
School Grade
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary & Emergency Contact Information
Primary Contact Name
First Name
Last Name
Relationship to Child
Mother
Father
Uncle
Aunt
Grand Parent
Family Friend
Other
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is the address same with the child?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
Please list who will be dropping off/picking up the camper
Camper will attend the Hirundo Camp on the following days:
Monday through Friday (5 days)
Monday, Wednesday, and Friday (3 days)
Tuesday and Thursday (2 days)
Participant Health Information
Primary Care Physician Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Dentist Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Does the child have any medical conditions?
Yes
No
Please give details
Does the child have any allergies to food, medications, or insect bites?
Yes
No
Please give details
I give Hirundo permission to administer the following medicines to my child:
Tylenol/Acetaminophen
Advil/Ibuprofen
Benadryl/Diphenhydramine HCl
Other
Medical Insurance Information
Insurance Company
Phone Number
Policy
Policy #
Group #
Policy Holder Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agreement & Consent
I, parent/guardian of the participant, agree with the following statements:
I understand that I am responsible for paying every week my child is enrolled in the Winter Camp Program. Payment is due at time of registration.
I give permission that my child may be photographed, videotaped, and/or interviewed for the purpose of the Camp's promotional use.
Consent is given for Hirundo Wildlife Refuge staff and volunteers to obtain or provide medical care for my child, or to transport them to a medical facility. I further authorize Hirundo Wildlife Refuge staff and/or volunteers to render such treatment they consider necessary for my child’s health and I agree to pay all costs associated with that care and transportation.
I understand that Hirundo reserves the right to call the parent to pick up the child in the event of illness, injury, or misconduct.
Each child needs to bring their own lunch provided it does not need heating or cooling, and is clearly labeled with the child’s name.
I understand that the camp is not responsible for any lost or stolen items while members and/or program participants are attending the camp.
I understand that there are risks inherent in any outdoor activity, I am voluntarily allowing my child to participate in the camp and I understand the camp is intending to seek out a natural wilderness experience. I am aware of the hazards involved in such activities and I made such inquiry and/or inspection and have taken such precautions as I believe are appropriate, and I assume all such risks and hazards of these and any related activities, which may include the following: Hiking at Hirundo may encounter hazards typical to the Maine woods, such as rugged paths, exposed tree roots, rough and/or slippery terrain, forest pests, insects, wild animals, and other people’s pets. Precautions should be taken against sunburn, heatstroke, hypothermia, frostbite, poison ivy, ticks, and infection. As part of the experience, we hope to view wildlife in its natural habitat, and such wildlife may be dangerous. Hirundo is remote, cell service may be weak, and emergency medical care may not be immediately available. In consideration for receiving permission to participate in the camp, I accept and assume full responsibility for all harm and injury, of every nature, including death and for all damages or loss to any personal property owned by me or damaged by me, while I am participating in Hirundo activities and during all travel and transportation. I understand the nature of the terrain and/or waterbodies and the type of activities my child will be participating in. My child agrees to go into only those areas authorized by Hirundo and to comply with all its rules concerning these activities. I agree that my child will take all reasonable precautions to avoid injury and damage to property in connection with activities. On behalf of myself, my heirs, successors and assigns, I hereby forever release, indemnify, defend, and hold harmless Hirundo, its Trustees, staff, employees, volunteers and agents, from and against any and all claims, liabilities, losses. I intend this release to be effective, regardless of whether the claim of liability is asserted in negligence, strict liability in tort, or other theory of recovery, INCLUDING AS A DIRECT RESULT of any negligent act of Hirundo, its Trustees, staff, employees, volunteers or agents. I acknowledge that I have read and understand this form, and that the statements that I have made in it are all true and that I am at least 18 years of age, or, if I am not 18 years of age, the signature and consent of my parent or legal guardian is included below.
Date
-
Month
-
Day
Year
Date
Signature
Clear
Camp Fees *Please Use Sibling2022 in Coupon Code for the 10% second child discount.
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Monday Through Friday
Full Week Camp Option
$
225.00
Monday, Wednesday, and Friday
Three Day Camp Option
$
150.00
Tuesday and Thursday
Two Day Camp Option
$
100.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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