Shake-A-Leg Miami - Adventure Island 2022

Camper Information

Camper's Name *

First Name Last Name

Camper's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Camper's Phone Number *

Area Code Phone Number

Camper's Email *

example@example.com

Camper's Birthdate *

Date

Camper's Gender *

Male Female

Camper's Ethnicity *

Hispanic or Latino or Spanish Origin Not Hispanic or Latino or Spanish Origin.

Camper's Race *

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multiracial

Is the Camper Proficient in English? *

Yes No

Other Language(s) Spoken in Camper's Home (Check any that apply)

Spanish Haitian Creole

Camper's Current School *

Camper's Current Grade *

Camper's Shirt Size *

Camper's Shoe Size *

Does the Camper Receive Any of the Following Assistance? (Check all that apply)

McKay Scholarship SNAP Government

Parent/Guardian Information

1st Parent/Guardian Name *

First Name Last Name

1st Parent/Guardian Phone Number *

Area Code Phone Number

1st Parent/Guardian Email *

example@example.com

2nd Parent/Guardian Name

First Name Last Name

2nd Parent/Guardian Phone Number

Area Code Phone Number

2nd Parent/Guardian Email

example@example.com

Emergency Contact Information

Emergency Contact Name (Non-Parent/Guardian) *

First Name Last Name

Emergency Contact Phone Number *

Area Code Phone Number

Adults Authorized to Pick Up the Camper

If you would like to authorize any non-parent adult to pick up the Camper from camp, please provide their information.

1st Authorized Adult Name

First Name Last Name

1st Authorized Adult Phone Number

Area Code Phone Number

2nd Authorized Adult Name

First Name Last Name

2nd Authorized Adult Phone Number

Area Code Phone Number

3rd Authorized Adult Name

First Name Last Name

3rd Authorized Adult Phone Number

Area Code Phone Number

Camper's Medical Information

Is the Camper prone to Startle Reflex or Seizures? *

Yes No

Does the Camper have any Allergies? *

Yes No

If Yes, please list all of the Camper's Allergies

Does the Camper take any Medications regularly? *

Yes No

If Yes, please list all of the Camper's medications

Does the Camper have a Disability or Special Need? *

Yes No

If Yes, Check any options below that describe the Camper's Disability or Special Need

What are the main ways in which the Camper communicates (Check all that apply)

Speaks and is easily understood Speaks but is difficult to understand Uses communication devices like pictures or a board Uses sign language Uses gestures or expressions like pointing, pulling, etc. Uses sounds that are not words like laughing, crying, etc.

Areas in which the Camper needs assistance (Check any that apply)

Academic, learning, reading activities Adapting to activities taking into account visual or hearing impairment Holding a crayon/pencil, writing, using scissors or other fine motor tasks Managing feelings and/or behavior Personal services like help with feeding, using the toilet, or changing clothes Sports or physical activities like running or other gross motor tasks Using adaptive device(s) like a wheelchair, crutches, brace, or walker

List any Accommodations needed

Additional Notes

Please let us know any notes or additional information we should know about the Camper

PLEASE CALL FOR 10% SIBLING DISCOUNT BEFORE SUBMIT PAYMENT (NO REFUNDS). *

Session 1: June 13 - June 17, 2022 $ 350.00

Session 2: June 20 - June 24, 2022 $ 350.00

Session 3: June 27 - July 1, 2022 $ 350.00

Session 4: July 4 - July 8, 2022 (discounted rate) $ 300.00

Session 5: July 11 - July 15, 2022 $ 350.00

Session 6: July 18 - July 22, 2022 $ 350.00

Session 7: July 25 - July 29, 2022 $ 350.00

Session 8: August 1 - August 5, 2022 $ 350.00

Session 9: August 8 - August 12, 2022 $ 350.00

Enter coupon

Total $ 0.00

Payment Information

Waiver of Liability Relating to Corona Virus/Covid-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is reported to be extremely contagious. Thestate of medical knowledge is evolving, but the virus is believed to spread from person-to-person contact and/or by contact with contaminated surfaces and objects, and even possibly in the air. People reportedly can be infected and show no symptoms and therefore spread the disease. The exact methods of spread and contraction are unknown, and there is no known treatment, cure, or vaccine for COVID-19. Evidence has shown that COVID-19 can cause serious and potentially life-threatening illness and even death. Shake-A-Leg-Miami (“SALM”) cannot prevent you or your child(ren) from becoming exposed to, contracting, or spreading COVID-19 while performing services, utilizing services, participating in programs, or while on SALM premises. It is not possible to prevent against the presence of the disease. Therefore, if you choose to volunteer, work, participate in, or utilize SALM’s services and/or enter onto SALM’s premises you may be exposing yourself to and/or increasing your risk of contracting or spreading COVID-19. ASSUMPTION OF RISK: I have read and understood the above warning concerning COVID-19. I hereby choose to accept the risk of contracting COVID19 for myself and/or my children in order to perform services for, utilize services of, participating in programs provided by, SALM, and enter SALM’s premises. I fully understand and accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to perform services on SALM’s property, utilize SALM’s services, participate in SALM’s programs, and enter onto SALM’s premises in person rather than arranging for an alternative method of performing these services or enjoying the same services virtually (e.g. videoconference). WAIVER OF LAWSUIT/RELEASE OF LIABILITY: I hereby forever release and waive any claim and cause of action and my right to bring suit against SALM and its officers, directors, managers, officials, trustees, agents, employees, or other representative in connection with exposure, infection, and/or spread of COVID-19 related to performing services or utilizing SALM’s services and coming onto SALM’s premises. I understand that this waiver and release means I give up my right to bring any claims and causes of action, including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages, whether known or unknown, foreseen or unforeseen. I agree to comply with all CDC, FDOH, City of Miami guidelines to reduce the contraction and/or transmission of COVID-19 by myself and/or my children and/or other members of my household. By signing this Agreement, I am representing that neither I nor my children nor other members of my household are experiencing any symptoms of COVID-19 including, but not limited to, fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea, any other flu-like illness, or skin lesions. I further represent that, as of the date of signing this Agreement, neither I nor my child/children nor any other member of my household are currently diagnosed with COVID-19 or have tested positive forCOVID-19. Finally, I represent that as of the date of signing of this Agreement and to the best of my knowledge (1) that I and/or my children and/or all other members of my household have not been in close contact with any individual who has tested positive for COVID-19 in the last fourteen (14) days; and (2) that neither my child/children, nor any member of my household, nor I have traveled outside of the United Sates in the last fourteen (14) days. Additionally, I acknowledge, understand, and agree that SALM WILL NOT PROVIDE masks for any participant including my child/children and I will be solely responsible for providing my own and my child/children with a mask daily for each participant and child. I understand that SALM WILL NOT ALLOW me to sign my child/children into SALM or have my child/children participate in any activity on SALM’s premises each morning unless my child/each of my children is wearing a mask. CHOICE OF LAW: I understand and agree that the law of the State of Florida will apply to this contract. I HAVE CAREFULLY READAND FULLY UNDERSTAND ALL PROVISIONS OF THIS RELEASE, AND FREELY AND KNOWINGLYASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE BY CHECKINGTHE “I AGREE” BOX.

I read and I agree with the above statement

Statements

In consideration of Shake-A-Leg Miami, Inc. (“SALM”) extending to me the opportunity to participate in SALM’s Summer Camp I fully assume all risks that might arise, both known or unknown, and both inherent to the program or activity in which I am engaging and any risks that are not inherent, and waive all liability for all such risks, including without limitation any potential liability that SALM may have for its own negligence or the negligence of any of its agents, officers, directors, or employees, in connection with my participation in the program or activity, and in particular, without limitation, to the extent permitted by law, I and my heirs, representatives, executors, or administrators and my undersigned parent, guardian or aide (if applicable) remise, release, indemnify, acquit and hold harmless and forever discharge SALM and its directors, officers, employees, agents, instructors, volunteers, rescue and support personnel, from any and all claims and liability, including without limitation liability for SALM’s and its directors’, officers’, employees’, agents’, instructors’, volunteers’, rescue and support personnel own negligence, and all obligations, damages, claims, causes of action, judgements, costs and charges which I may suffer or which may be incurred by me for any reason of any occurrence during my travel to and from the activity or program, and during my participation therein, whether resulting from any acts, omissions or negligence or from acts of God or nature. I also agree to assume liability for all and any damages to SALM property that is under my control while participating in any SALM activity. During my participation, I hereby agree to comply with all SALM rules and regulations, applicable county and municipal ordinances, and with the laws of the State of Florida and the United States. *

I have read and agree with the above terms.

I hereby give my full and unconditional permission to SALM for the free use of my and the Camper's name, likeness, and image (including without limitation permission to use any photo and video in which I may appear) in any present or future media story, promotion, advertisement, or account of an SALM related program, event, or activity, including without limitation in connection with any present or future public relations or fundraising event or activity. *

Yes No

Click here to download the Medical Authorization Documents

It is my responsibility to submit a Medical Authorization Document, which can be downloaded using the link above. *

I agree with the above statement

I understand I will need to provide the registered nurse with a prescription from the doctor for any medications that need to be administered by the nurse during camp hours. *

I agree with the above statement

Email Associated with Credit Card

example@example.com

I understand the sibling discount code does not apply for the first applicant. The sibling discount code applies to each additional applicant. I understand I will not receive a refund if I choose not to attend this camp. *

Yes

Shake-A-Leg Miami - Adventure Island Summer Camp 2022

Payment Information

COVID LIABILITY WAIVER STATEMENT