Summer Camp Detailed Registration Form

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.

Child Name: *

First Name Last Name

Date of Birth: *

Month Day Year

Age: (child must be at least 6 years of age to participate in this program) *

Gender: *

Male Female

School:*

Site Preference: (please note specific times of operation for each location) *

NOTE: Big Elm Elementary, Johnson Elementary (at Compton Park) and Nutter Fort Elementary programs will run Monday - Thursday from June 21st -July 15th. - - - - - - - - - - - - - HCPR Complex, North View Elementary, and West Milford Elementary programs will run Monday - Friday from June 21st - July 29th.

Parent/Guardian Information:

Name *

First Name Last Name

Name *

First Name Last Name

Primary Address of Child *

Street Address

Mailing address (if different)

City State / Province

Postal / Zip Code

Home Number: (enter cell if no home phone) *

Cell Number: MAKE SURE YOU ANSWER CALLS DURING PARK PROGRAM AND VOICEMAIL IS SET UP AND NOT FULL!!! *

E-mail *

example@example.com

Secondary Parent/Guardian (If applicable):

Street Address

Mailing address (if different)

City State / Province

Postal / Zip Code

Home Number:

Cell Number:

E-mail

example@example.com

Emergency Information:

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Alt. Phone Number

Other Information: Are there any accommodations needed that Harrison County Parks and Recreation needs to be aware of? All accommodations requests should be made far in advance as possible, as accommodation process may take time to complete.

Media Release: Please Choose 1 *

I DO NOT consent to the publication of the image and likeness of the above named participant to be videotaped, audiotaped or photographed. I hereby give my consent for the image and likeness of the above named participant to be video taped or photographed for the following uses: Educational/Instructional Media, Recruitment / Outreach Media, Development Media, Newsworthy Media Documentation.

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.

Signature *

Clear

Date *

Date

Harrison County Parks and Recreation
Instructions for Program Dismissal

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

my child...

must be picked up by: (Photo ID Required) (Sign in/Sign out forms MUST be complete) IF SELECTING THIS OPTION PERSONS ALLOWED BELOW MUST BE COMPLETED ENTIRELY!

1) Person allowed to pick up child:

Name AND WVDL# or ID# MANDATORY INFORMATION

Relationship

Phone Number

2) Person allowed to pick up child:

Name and WVDL# or ID#

Relationship

Phone Number

my child...

may be released to walk home with:

Name/relationship/phone number

May be released to walk home alone

My child/children can leave (select one)

anytime specific time (indicate below)

Release my child at:

Hour Minutes

AM/PM Option

Any additional special instructions for dismissal:

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: *

Signature *

Clear

Date *

Date

Insurance Information:
Is the participant covered by family medical/hospital insurance:   Yes   No*
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: NUMBER ONLY*

Allergy Information:
Does your child have allergies?:   Yes   No*
If YES, does your child carry emergent medication, such as an EPI-PEN or Inhaler?
Yes   No*
If YES, has your child ever been hospitalized for these allergies?   Yes   No*

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?

Please indicate below:

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.

Signature *

Clear

Date *

Date

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.

Harrison County Parks & Recreation