2020 MKI Camper Health Form

Mountain Kids Incorporated

2024 Summer Camp Health Form
2024 MKI Camper Health Form
Camper Name*

First NameLast Name
Preferred First Name*
Date of Birth

MonthDayYear
Date
Emergency Contact
Emergency Contact #1*
Name
Phone Number*
Relationship to Child*
Mother, Father, Grandparent, etc.
Emergency Contact #2*
Name
Phone Number*
Relationship to Child*
Child Pick-Up Restrictions

Please list authorized adults NOT allowed to pick up your child.
Individual #1
Individual #2
Individual #3
Health Information
Insurance Company*
Insurance Policy #
Is camper free from infectious desease or conditions?*

YesNo
Has the child had a tetanus shot within the past 10 years?*

YesNo
Are immunizations up to date?*

YesNo
May we apply sunscreen to the camper?*

YesNo
Any physical, mental or other condition that would require special attention or medication while in class?
List any allergies (ex: bees,peanuts, dairy), and the severity of the allergy.
Any activity the camper should be restricted from?
Any dietary needs that we should know about? Are you able to provide your own food if you have specific needs?
List any past medical treatment that would be helpful for us to know.
List all medications the student takes on a regular basis.
Health Release/Waiver
By clicking submit and electronically signing, I agree that I am the parent or legal guardian of the above named child, and am over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. I give my permission for Mountain Kids, Incorporated to transport, or call an ambulance, to take my child to a medical/dental facility, if necessary. In case of emergency, if none of the emergency contacts respond, I hereby give my consent for emergency medical care to be prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I accept full responsibility for all costs of said medical care and any emergency treatments. Mountain Kids, Incorporated will not be held responsible for the cost of any medical or dental care, or emergency treatments. I hereby waive all claims whatsoever in connection with such medical treatments.

PHOTO RELEASE: Mountain Kids, Incorporated will include photos of students, teachers, volunteers, and camp activities on its website and printed materials. I understand that these pictures will be accessible to anyone with internet access. I give my permission for Mountain Kids, Incorporated to use photos of my child/children on its website, on Facebook, in printed materials, and in electronic forms of communication. I understand that if I do not want images of my child to be used, I will indicate this in writing and the signed letter will be mailed to: MKI, 630 Estates Drive, Pounding Mill, VA 24637.

WAIVER AND RELEASE: I agree that if my dependent or I (heretofore known as "we") engage in any physical activity, class, or activity, or facility on the premises or any venue where we participate as a representative of Mountain Kids Incorporated, we do so at our own risk. I agree that we are voluntarily participating in activites and use of said facilities, premises (including the parking lot) and designated Mountain Kids Incorporated venues. We assume all risk of injury, illness, damage, or loss to us or our personal property that might result, including, without limitation, any loss or theft of any personal property. I agree that this consent and assumption of risk statement covers each and every event or activity sponsored by Mountain Kids, Incorporated. I agree to release and discharge you (and your affiliates, employees, assistants, volunteers, agents, representatives, successors, and assigns) from any and all claims or cause of action (known or unknown) arising out of your negligence. I acknowledge that I have carefully read this Waiver and Release and fully understand that it is a release of liability. I am waiving any right that I may have to bring legal action to assert a claim against you for negligence.

DECLARATION: By electornically signing below, I confirm that I have read the document in its entirety. I understand the document, have had an opportunity to ask questions, and agree to be bound by its terms.
I AGREE to all terms listed above, by electronically signing*
Enter the message as it's shown*
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Mountain Kids Incorporated

2024 MKI Camper Health Form

Emergency Contact

Child Pick-Up Restrictions

Health Information

Health Release/Waiver