• AndrewsCamps/Clark Creek Lodge

    Required Registration Forms - Annual Update 2022
  • STATE or CALIFORNIA-HEALTH AND HUMAN SEIVICES AGENCY
    CALIFORNIA DEPARTMENT or SOCIAL SERVICES

  • CA LIC FORM 702 - CHILD'S HEALTH HISTORY

  • LIC FORM 627 (9/08) (CONFIDENTIAL)

    CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
    CONSENT FOR EMERGENCY MEDICAL TREATMENT


    AS THE PARENT OR GUARDIAN, I HEREBY GIVE CONSENT TO ANDREWSCAMPS TO OBTAIN ALL EMERGENCY MEDICAL OR DENTAL CARE PRESCRIBED BY A DULY LICENSED PHYSICIAN (M.D.) OSTEOPATH (D.O.) OR DENTIST (D.D.S.) FOR THE CHILD NAMED ABOVE. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF THE CHILD NAMED ABOVE.

  • LIC FORM 613A - PERSONAL RIGHTS

    Section 101223 conditions applicable to Child Care Centers.

    (a) Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are not limited to, the following:

    1. To be accorded dignity in his/her personal relationships with staff and other persons.
    2. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
    3. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
    4. To be informed, and to have his/her authorized representative, if any, informed by the licensee of the provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.
    5. To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor   of his/her choice. Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis. In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.
    6. Not to be locked in any room, building, or facility premises by day or night.
    7. Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing agency.
  • LIC FORM 995A - NOTIFICATION OF PARENTS'RIGHTS

    As a Parent/Authorized Representative, you have the right to:

    1. Enter and inspect the family child care home without advance notice whenever children are in care.
    2. File a complaint against the licensee with the licensing office and review the licensee's public file kept by the licensing office.
    3. Review, at the family child care home, reports of licensing visits and substantiated complaints against the licensee made during the last three years.
    4. Complain to the licensing office and inspect the family child care home without discrimination or retaliation against you or your child.
    5. Be notified and receive, from the licensee, a written notice that lists the name of any person not allowed in the family child care home while children are present. (NOTE: This notice is only required when the Department has, in writing, excluded someone from the family child care home on or after January 1, 2001
    6. Request in writing that a parent not be allowed to visit your child or take your child from the family child care home, provided you have shown a certified copy of a court order.
    7. Receive from the licensee the name, address and telephone number of the local licensing office.
    8. Be informed by the licensee, upon request, of the name and type of association to the family child care home for any adult who has been granted a criminal record exemption, and that the name of the person may also be obtained by contacting the local licensing office.

    NOTE: CALIFORNIA STATE LAW PROVIDES THAT THE LICENSEE MAY DENY ACCESS TO THE FAMILY CHILD CARE HOME TO A PARENT/AUTHORIZED REPRESENTATIVE IF THE BEHAVIOR OF THE PARENT/AUTHORIZED REPRESENTATIVE POSES A RISK TO CHILDREN IN CARE.

  • P1 ACKNOWLEDGEMENT OF RISK, WAIVER AND RELEASE OF LIABILITY 

    SECTION 1. I understand and acknowledge that participation in the camps, events, after school programs, birthday parties, Clark Creek overnight camps or other programs operated or conducted by AndrewsCamps LLC and/or Andrew A Frierson d/b/a/ AndrewsCamps (the "Camp"), including all of its activities and the use of its facilities and equipment, involves an inherent and unavoidable risk of injuries, harm, and loss. I understand that although the Camp takes reasonable precautions toprovide proper organization, supervision, and equipment, there are numerous risks associated with participating in the Camp's activities, including, but not limited to, the use of playgrounds, ATVs, inflatable equipment, zip lines, game room equipment, electronic devices. camp-provided food, as well as participation in sports and active games, sewing and knitting activities, Maker activities/projects, and baking activities. Equipment used in activities may break, fail, or malfunction and cause injury. Some of the equipment used in activities may cause injuries even when used as intended. These are some, but not all, of the risks inherent in Camp activities; a complete listing of inherent risks is not possible and some risks cannot be anticipated.

    SECTION: 2. I authorize the child/children named herein to participate in the camps and all activities operated by the Camp for which I register, both on and off site. On my own behalf and on behalf of the child/children named in this registration, ACKNOWLEDGE THE RISKS associated with participation in the various camps and programs offered by Camp and I expressly and voluntarily assume the risks of participation in the camps and activities operated by the Camp and HEREBY

    WAIVE AND RELEASE ALL CLAIMS, DEMANDS, ACTIONS, CAUSES OF ACTION, COSTS, LOSSES, EXPENSES AND LIABILITIES ("CLAIMS") (WHETHER ON BEHALF OF THE CHILD/CHILDREN NAMED IN THIS REGISTRATION OR FOR MY OWN BENEFIT) AGAINST THE CAMP (INCLUDING ITS STAFF, EMPLOYEES, AND AGENTS) THAT MAY ARISE FROM INJURIES, HARM OR LOSS RESULTING FROM PARTICIPATION IN THE CAMPS AND ACTIVITIES OPERATED BY THE CAMP, INCLUDING (WITHOUT LIMITATION) ANY CLAIMS ALLEGING NEGLIGENCE BY THE CAMP (INCLUDING

    ITS STAFF, EMPLOYEES, AND AGENTS), to the fullest extent allowed under the laws of the state of California or any other jurisdiction in which the camp. program or event where your child/children attends or participates is located. If any aspect of this waiver is deemed to be invalid, I acknowledge that the remainder of the agreement will continue to have full force and effect. If my agreement on behalf of my child/children to release any Claims against the Camp is deemed invalid for any reason, I agree to indemnify. defend and hold the Camp harmless in connection with any Claims arising out of my child's children's participation in the camps, programs, events and activities operated by the Camp, including payment of reasonable defense costs incurred by the Camp.

    SECTION 3. I hereby authorize the staff of the Camp to act according to their best judgment in any situation requiring medical attention for the child/children named herein. I understand that it is my responsibility to provide medical insurance coverage for the child/children named herein while they are attending camps operated by the Camp and to provide accurate and complete medical information. I attest that all immunizations for the child/children named herein that are required by their school or local school district are up-to-date. (including. but not limited to, a COVID vaccination I understand that the Camp may require me to present proof of vaccination at any time. I further understand that, in order to help ensure the health and safety of campers and staff, the Camp does not allow exceptions to this policy for any non-medical, religious or philosophical reasons. The only exceptions that will be made are in instances where a child cannot safely receive vaccinations for medical reasons, and such exceptions will be made by the Camp Headquarters on a case-by-case basis only upon presentation of a letter of explanation from a physician licensed in the state where the child is attending Camp providing the Camp with sufficient information to evaluate the need for an exception. I acknowledge that the costs of any medical treatment provided to the child/children named herein that are not covered by medical insurance will be my sole responsibility, consistent with the waiver of Claims above.

     

  • P2 ACKNOWLEDGEMENT OF RISK, WAIVER AND RELEASE OF LIABILITY (CONTINUED)

    SECTION 4. The Camp reserves the right to expel or to deny re-enrollment or participation of any child/children if, in the Camp's sole and absolute discretion, (i) the actions of a child/children or their parent/guardian disrupt, impede or interfere with the Camp's ability to maintain a positive and constructive relationship with all participants and their parents/guardians (including but not limited to non-payment of Camp fees), (ii) such actions threaten the safety of the child/children, other children, or Camp staff, (iii) such actions otherwise interfere with the Camp's accomplishment of its mission, or (iv) if expulsion or refusal to re-enroll would be in the best interest of the camper or the Camp. The Camp will make every attempt to communicate with the child/children and their parent/guardian regarding any actions that would puta child/children at risk of a pause in enrollment, expulsion or denial of re-enrollment. If, in its sole and absolute discretion, the Camp decides to expel or refuse enrollment or participation to a child/children, any fees paid for unused days, if applicable, would be refunded.

    SECTION 5. As to any child/children who are enrolled in a camp operated by the Camp, I agree that the Camp (including its staff, employees and agents) can take and use photos, video and audio recordings of the child/children named in this registration for the limited purposes of marketing the Camp which may be publicly available on the internet, without compensational obligation, and I hereby release the Camp (including its staff, employees and agents) from any Claims resulting from their use of photos. videos and audio recordings (Please note: if you want to understand why we seek your consent for this or to request that we do not publicly use photos, videos and/or audio recordings featuring your child/children, contact photopolicy@andrewscamps.com) I agree to receive periodic email, text messages, phone or written communication from the Camp regarding products, services or information that may be of interest to me.

    SECTION 6. Further, I acknowledge and agree that the child/children and myself and any co-parent or co-guardian, are not allowed to take, and shall not take, any photographs, video, or audio recordings of other children or other parents/guardians participating in camps, events, or programs without their express consent, and are not allowed totransmit, upload, or post such content online or electronically including on any social media or similar site, or use or publish such content in any non-personal media such as a book, video, film, television program or publicly viewable website. Upon the Camp's request, I agree to delete and/or remove such content from any device, site, platform, or other media, if, in the Camp's sole and absolute discretion, such content and/or the manner in which it is presented violates the terms of this agreement, is objectionable, inappropriate, or violates the privacy rights or right of publicity of others.

    SECTION 7. As to any child/children who are enrolled in a camp operated by the Camp, I hereby authorize the Camp to withdraw from my bank account or charge my credit/debit card the full cost of the camp day(s) and/or after school programs, no school day camps, holiday camps, Clark Creek Lodge registrations or other services that I have or may in the future elect to purchase. In the event that there are insufficient funds in my bank account or my credit card is declined at the time of processing, I authorize the Camp to reattempt to process my payment method again until those funds are successfully collected, and I agree to provide an alternate payment method as required by the Camp.

  • I hereby confirm that I am the person identified as Parent/Guardian above and that I have legal standing to complete this document which I have done truthfully and to the best of my ability. I further confirm that I understand and accept the terms presented in the several documents which are herein being completed and of which I acknowledge receiving a copy.

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  • STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY                                                                                                                                          CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

     

    PERSONAL RIGHTS

    Child Care Centers

     

    Personal Rights, See Section 101223 for waiver conditions applicable to Child Care Centers.

    (a)    Child Care Centers. Each child receiving services from a Child Care Center shall have rights which include, but are
            not limited to, the following:

    (1)    To be accorded dignity in his/her personal relationships with staff and other persons.

    (2)    To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her

    needs.

    (3)    To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion,

    threat, mental abuse, or other actions of a punitive nature, including but not limited to:  interference with daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

    (4)    To be informed, and to have his/her authorized representative, if any, informed by the licensee of the

    provisions of law regarding complaints including, but not limited to, the address and telephone number of the complaint receiving unit of the licensing agency and of information regarding confidentiality.

    (5)     To be free to attend religious services or activities of his/her choice and to have visits from the spiritual advisor

    of his/her choice.  Attendance at religious services, either in or outside the facility, shall be on a completely voluntary basis.  In Child Care Centers, decisions concerning attendance at religious services or visits from spiritual advisors shall be made by the parent(s), or guardian(s) of the child.

    (6)    Not to be locked in any room, building, or facility premises by day or night.

    (7)    Not to be placed in any restraining device, except a supportive restraint approved in advance by the licensing

    agency.

     

     

    THE REPRESENTATIVE/PARENT/GUARDIAN HAS THE RIGHT TO BE INFORMED OF THE APPROPRIATE LICENSING AGENCY TO CONTACT REGARDING COMPLAINTS, WHICH IS:

     

     

     

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