SATURDAY CAMP MIRACLES ENROLLMENT

SATURDAY CAMP MIRACLES ENROLLMENT

Saturday Camp Miracles is here! You can either fill out this form in person or online. This is for liability purposes as well as us having an idea of who will be attending. The location is Beckett Life Center 1410 N 16th St. We complete this process in the Fall of each year to ensure we have the most updated information to keep your child(ren) safe. We are looking forward to another incredible season!
Parent/Guardian Contact Information
Parent/Guardian Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone Number*
Please enter a valid phone number.
Add another Parent/Guardian

YesNo
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Phone Number
Please enter a valid phone number.
Participant Information
Name*

First NameLast Name
Age*
T-shirt size*
Birthday*

MonthDayYear
Date
Allergies/ Dietary Restrictions
School attending
Grade in the Fall
Does your child have an IEP?

YesNo
Please upload the IEP or email information you are willing to share to Laura.hicks@odaatphilly.org. You can also email to set up time to talk about how we can best support your participant.

Cancelof
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Relationship to Participant*
Authorized Pick Up Person(s) : add as many contacts as you'd like*
PLEASE REVIEW AND SIGN THE CONSENT AGREEMENT
I hereby give my permission for my child(ren) to participate in Saturday Camp Miracles ("Program").

Participation in any program which involves physical activity exposes the camper to certain risks and dangers. Accidents and injuries are always a possibility, and it is impossible to foresee and protect the camper from all conceivable dangers.

I hereby affirm that my child(ren) has/have no conditions that would make it unsafe for him/her/them to participate in the program session(s) selected.

I acknowledge that COVID is still contaigious and participants are susceptible to contracting the virus. Please consider taking proper precautions to ensure that your participant and other participants are safe.

Medical Consent: I understand that the Program will make every effort to contact me in the case of an emergency. I give my permission for the Program to administer any medications needed and to provide and arrange for and consent to any necessary medical treatment for my child(ren) while at Saturday Camp Miracles.

Photography Release: In consideration of child(ren)’s participation at the Program, and without any further consideration from the Program, I hereby grant permission to the Program staff and affiliates to utilize my child(ren)’s appearance, performance or voice in any and all manner and media throughout the world for the purpose of promotion, reporting or publication. The Program may use my child(ren)’s, likeness, voice and biographical material in connection with publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph.

By signing this Waiver and Release of Liability, with full appreciation of the risk involved, on my own behalf and on behalf of my child(ren), I hereby voluntarily release and forever discharge the Program, its trustees, officers, employees, agents, insurers and contractors from any and all legal or financial responsibility for any personal injury, disability, illness, damage, medical expense or death, arising from or related to my child(ren)’s participation in the Program. I agree, for myself and my child(ren), not to make any type of legal or equitable claim on the program, or any of its trustees, officers, employees, agents, insurers or contractors with respect to any injury I or my child(ren) may suffer, whether or not it arises through the negligence, omission, default or other action of anyone affiliated with the Program, including other campers. I further agree that if any such claim is made, I will indemnify and defend the Program with respect to any such claim, injury or damage.
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SATURDAY CAMP MIRACLES ENROLLMENT

Parent/Guardian Contact Information

Participant Information

Emergency Contact Information

PLEASE REVIEW AND SIGN THE CONSENT AGREEMENT