• Harrison County Parks & Recreation

    Summer Park Program Child Enrollment Application
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    ATTENTION
    IF YOU HAVE ARRIVED AT THIS APPLICATION VIA 
    THE HARRISON COUNTY SCHOOLS SUMMER RE-TEACH PROGRAM

    WE RECCOMEND YOU UTILIZE THE SUMMER PLAYGROUND PROGRAM 
    AT THE LOCATION YOUR CHILD IS ATTENDING, 
    AS TRANSPORTATION TO OTHER SITES WILL NOT BE PROVIDED .
    PLEASE CONTACT US AT 304-423-7800
    IF YOU HAVE ANY ADDITIONAL QUESTIONS

    PLEASE NOTE:
    HCPR Staff will not be responsible for any personal items brought to the program's sites. Including but not limited to cell phones or other electronic devices.

     

    Participant Information:
    You must fill out individual forms for each child being registered in the program.

  • School:*

  • Parent/Guardian Information:

  • Emergency Information:

  • IF CONSENT GRANTED ABOVE: You further authorize Harrison County Parks and Recreation to use electronic media and/or photographs in any manner - whole or in part. This waiver includes usage of this media in any way deemed appropriate, which may include electronic and photographic reproductions thereof for the production of educational, instructional, promotional or institutional advancement materials, which support the activities of the Harrison County Parks and Recreation from all liability which could result from its use.

  • Disclosure Agreement: I / We the parents and/or guardians of the above named participant in the named HCPR Program hereby give my/our approval to participate in any and all activities. I/we assume all risks and hazards incidental to such participation, including transportation to and from the activities, and I/we do hereby waive, release, absolve, indemnify and agree to hold harmless the Harrison County Parks and Recreation and its staff, the Harrison County Commission, property owners, sponsors, participants and persons transporting my/our child to and from activities; for any claim arising out of the injury or property damage to my/our child. The undersigned consents to any and all emergency medical treatment which may be deemed advisable by his/her physician or emergency squad. The intention being to grant authority for emergency transportation and t administer any examinations, diagnostic procedures, and treatment deemed necessary if contract cannot be made with Parent or Guardian. Parent or Guardian will be responsible for all costs incurred. The undersigned also assumes responsibility to read, acquire understanding of, and abide by all rules and program objectives and to inform the staff of all pertinent medical information for the participant. I/we agree to return upon request any equipment issued to my/our child in as good as condition as when issued except for normal wear and tear. I/we will furnish a copy of a birth certificate, and a copy of grade verification (when required) of the above named candidate to the HCPR staff at the time of registration.

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  • Harrison County Parks and Recreation
    Instructions for Program Dismissal

  • Please indicate how your child is to be dismissed by selecting one:

  • NOTE:
    This information is collected for the safety of your children.
    All information is only for use of HCPR and its staff. No information is given out.

  • Medical Release and Authorization As Parent and/or Guardian of the named athlete, 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  {Organization} . and its affiliates including Directors, Coaches, and Team Parents 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.
  • SECURITY QUESTIONS:
    What was your High School Mascot: *
    What is your mother's maiden name: *
    What is the name of your first pet: *

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  • Insurance Information:
    Is the participant covered by family medical/hospital insurance:      *   
    IF NO ENTER N/A IN INSURANCE INFO BELOW
    name of insurance company:*
    Group number:   *   
    Name on insurance card: *
    Phone Number:   *   

    Physician Information:
    Physician name: *
    Phone number: *

    Allergy Information:
    Does your child have allergies?:      *   
    If YES, does your child carry emergent medication, such as an EPI-PEN or Inhaler?
       *   
    If YES, has your child ever been hospitalized for these allergies?      *    

    Medication Information: By Harrison County Commission Policy, it states that NO EMPLOYEE will be allowed to administer any medication to any participant in the program under any circumstances whatsoever. This includes all prescription, over the counter and all other medication. Also, preventative measures such as lotions of any kind to help block the sun or for summer related injuries.

    Other Pertinent Health Information: Is there any additional information about your child's health that you think is important or that may impact their ability to participate in this program?

  • Accuracy Statement:
    This health form is correct and complete as far as I know and the person herein described has permission to engage in all event activities except as noted. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. 

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  • Confirmation BY ACKNOWLEDGING AND SIGNING ALL SECTIONS HEREIN, I UNDERSTAND 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.

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