Summer Camp Detailed Registration Form

Child's Name*

First NameLast Name

Preferred Name/Nickname if Applicable

Gender and Pronouns*

Ex. "girl, she/her/hers"

Birth Date*

MonthDayYear

Grade

We're accepting campers in grades 2-5!

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell Number*

E-mail*

example@example.com

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number

Does the child have any allergies, chronic illnesses, or medical conditions? If yes, please describe.

Is the child prescribed an inhaler, epi-pen, or any medicines that camp counselors will need to be in charge of? If yes, please explain any instructions.

Which morning sessions (8:30-12:30pm) are you signing up for?*

Week 1 - June 24-28Week 2 - July 1-5Week 3 - July 8-12Week 4 - July 15-19

Which afternoon sessions (1:30-5:30pm) are you signing up for?*

Week 1 - June 24-28Week 2 - July 1-5Week 3 - July 8-12Week 4 - July 15-19

Every camp session will include snack time. Will your camper bring their own snack or eat a snack provided by camp staff?*

My camper will arrive each day with a personal snackMy camper will eat a snack provided by camp staff

We ask that campers arrive each day with their own bottle of sunscreen. In the event that your child arrives without sunscreen, is it alright for them to use sunscreen supplied by camp staff?*

Yes, it is alright for my child to use sunscreen provided by camp staff

Camp activities may include coloring and drawing. Are you able to send your child to camp with markers/colored pencils and/or a clipboard to draw on?

Yes on markers/colored pencilsNo on markers/colored pencilsYes on clipboardNo on clipboard

Informed Consent and Acknowledgement

NOTICE: The following acknowledgment and authorization only regard the Island Explorer Summer Camp program, run by Island Explorers LLC, and its two authorized representatives, Asher Porad and Sam Ceballos-Lewin.

I hereby give my approval for my child’s participation in any activities conducted by Island Explorers Summer Camp, a program by Island Explorers LLC, during the selected camp. In exchange for the acceptance of said child’s candidacy by Island Explorers Summer Camp, I assume all risks and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless Island Explorers LLC and all its respective officers, agents, and representatives from any liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Island Explorers LLC, including all representatives and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports and outdoor activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

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 a significant accidental injury, I understand that the attending physician will make every attempt 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 Island Explorers Summer Camp, a program by Island Explorers LLC, and its staff to provide the needed emergency treatment before the child’s admission to the medical facility. Island Explorers Summer Camp and its staff cannot be held financially responsible for any medical treatment(s) that the minor child may require.

Release authorized on the dates and/or duration of the camp(s) which the minor child is scheduled to attend.

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 the life and limb of the named minor child, in my absence.

Confirmation

By acknowledging and signing below, 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.

Date*

Date

Signature*

Island Explorers Summer Camp Registration

Camper Information

Logistical Information