Example Group - Mud Weekends 2024

Example Group 2024 Mud Weekend - Complete Paperwork
Please take your time filling this out fully and accurately.
You Are A(n)*

Adult leader (18+)Parent/guardian of a camper
Your information

This form is to be completed by an ADULT LEADER for themself or by a PARENT or GUARDIAN on behalf of their camper. If you are a parent or guardian, you'll fill in your camper's info in a bit.
Your Full Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Birthdate*

MonthDayYear
Date
Your Gender*

FemaleMale
Which camp are you or your camper attending?*

Camp 1: 11/1 - 11/3 (Middle School)Camp 2: 11/8 - 11/10 (Middle School)Camp 3: 11/15 - 11/17 (High School)Camp 4: 11/22 - 11/24 (High School)Camp 5: 12/6 - 12/8 (Middle and High School)
Camper's Information

Awesome! We're excited to host your camper soon! Please let us know who they are by filling out this section.
Camper's Full Name*

First NameLast Name
Camper's Birthdate*

MonthDayYear
Date
Camper's Current Grade*

6789101112Other
Camper's Gender*

FemaleMale
Is Camper's home address the same as yours?*

Yes (will copy your address below)No (enter new address for camper)
Camper's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Emergency Contact 1*

First NameLast Name
Emergency Contact 1 Relation to Camper*
Emergency Contact 1 Relation to You*
Emergency Contact 1 Phone Number*
Please enter a valid phone number.
Emergency Contact 2*

First NameLast Name
Emergency Contact 2 Relation to Camper*
Emergency Contact 2 Relation to You*
Emergency Contact 2 Phone Number*
Please enter a valid phone number.
Health History, Medication, & Health Insurance Information
Camper's Health History
Does the camper have any of the following?*

Ear infectionsHeart diseaseSeizuresDiabetesBleeding disorderChicken PoxAsthmaNoneOther
Does the camper use insulin to manage their Diabetes?*

YesNo
Does the camper use an inhaler to manage their Asthma?*

YesNo
Does the camper have any medication allergies?*

YesNo
Please list the camper's medication allergies*
Information about dietary restrictions

Laurelville Retreat Center is our campground partner for Mud Weekends. Laurelville Retreat Center manages the facilities, including the kitchen. Below, you'll find their Dietary Policy.

At Laurelville Retreat Center we aim to create environments that allow participants to participate in our ministry in a safe and healthy way. Our Food Service Department strives to meet the needs of those we serve. We are pleased to offer gluten free, dairy free, peanut/tree nut free and vegetarian/vegan options. If any member of your group has allergy/dietary restrictions that fall into any of these four categories, or if you have an allergy not listed, please provide us with a list including the individuals’ names and needs at least one full week prior to your stay. If we do not receive advanced notice of needs, we cannot guarantee accommodation. During your stay, please have participants with dietary needs check in with the food service staff during meal times so that they can provide them either with instructions, or specially prepared food for that meal. We will provide a copy of the menu upon request.

If someone’s allergy/dietary needs exceed what we are able to accommodate, or if you have questions about our dietary policy, please contact our Guest Services Director Hannah Kupets, at hannah@laurelville.org.
Does the camper have any food allergies or dietary restrictions?*

YesNo
Please mark any food allergies or dietary restrictions that apply*

Gluten FreeDairy FreeNut FreeVegetarianOther
Additional comments about camper's food allergies
Does the camper have any physical limitations?*

YesNo
Comments about the camper's physical limitations*
Are all of the camper's immunizations up to date?*

YesNo
Please explain*
Are you aware of any current infectious diseases currently affecting the camper?*

YesNo
Comments about infectious diseases currently affecting the camper*
Does the camper have any special health/behavioral considerations we should be aware of?*

YesNo
Comments about the camper's special health/behavioral considerations*
Health History
Do you have any of the following?*

Ear infectionsHeart diseaseSeizuresDiabetesBleeding disorderChicken PoxAsthmaNoneOther
Do you use insulin to manage Diabetes?*

YesNo
Do you use an inhaler to manage Asthma?*

YesNo
Do you have any medication allergies?*

YesNo
Please list your medication allergies*
Please mark any food allergies that apply*

GlutenDairyTree nutsPeanutsOther
Information about dietary restrictions

Laurelville Retreat Center is our campground partner for Mud Weekends. Laurelville Retreat Center manages the facilities, including the kitchen. Below, you'll find their Dietary Policy.

At Laurelville Retreat Center we aim to create environments that allow participants to participate in our ministry in a safe and healthy way. Our Food Service Department strives to meet the needs of those we serve. We are pleased to offer gluten free, dairy free, peanut/tree nut free and vegetarian/vegan options. If any member of your group has allergy/dietary restrictions that fall into any of these four categories, or if you have an allergy not listed, please provide us with a list including the individuals’ names and needs at least one full week prior to your stay. If we do not receive advanced notice of needs, we cannot guarantee accommodation. During your stay, please have participants with dietary needs check in with the food service staff during meal times so that they can provide them either with instructions, or specially prepared food for that meal. We will provide a copy of the menu upon request.

If someone’s allergy/dietary needs exceed what we are able to accommodate, or if you have questions about our dietary policy, please contact our Guest Services Director Hannah Kupets, at hannah@laurelville.org.
Do you have any food allergies?*

YesNo
Additional comments about your food allergies
Do you have any physical limitations?*

YesNo
Comments about your physical limitations*
Are all of your immunizations up to date?*

YesNo
If "no" please explain*
Are you aware of any current infectious diseases currently affecting you?*

YesNo
Comments about infectious diseases currently affecting you*
Do you have any special health/behavioral considerations we should be aware of?*

YesNo
Comments about your special health/behavioral considerations*
Additional Notes for Camp Health Officer
Medications

For camp licensing purposes, we consider "medication" to mean any medications, including medications/supplements that do not require prescriptions.
Will the camper be taking any medications while at camp?*

YesNo
Will you be taking any medications while at camp?*

YesNo
Please note that all medications coming to camp MUST be in their original labeled container.
Medication 1 Name*
Medication 1 Dosage*
Medication 1 Dosage Unit*
Medication 1 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 1 Instructions*
Add Another Medication?*

YesNo
Medication 2 Name*
Medication 2 Dosage*
Medication 2 Dosage Unit*
Medication 2 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 2 Instructions*
Add Another Medication?*

YesNo
Medication 3 Name*
Medication 3 Dosage*
Medication 3 Dosage Unit*
Medication 3 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 3 Instructions*
Add Another Medication?*

YesNo
Medication 4 Name*
Medication 4 Dosage*
Medication 4 Dosage Unit*
Medication 4 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 4 Instructions*
Add Another Medication?*

YesNo
Medication 5 Name*
Medication 5 Dosage*
Medication 5 Dosage Unit*
Medication 5 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 5 Instructions*
Add Another Medication?*

YesNo
Medication 6 Name*
Medication 6 Dosage*
Medication 6 Dosage Unit*
Medication 6 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 6 Instructions*
Add Another Medication?*

YesNo
Medication 7 Name*
Medication 7 Dosage*
Medication 7 Dosage Unit*
Medication 7 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 7 Instructions*
Add Another Medication?*

YesNo
Medication 8 Name*
Medication 8 Dosage*
Medication 8 Dosage Unit*
Medication 8 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 8 Instructions*
Add Another Medication?*

YesNo
Medication 9 Name*
Medication 9 Dosage*
Medication 9 Dosage Unit*
Medication 9 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 9 Instructions*
Add Another Medication?*

YesNo
Medication 10 Name*
Medication 10 Dosage*
Medication 10 Dosage Unit*
Medication 10 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 10 Instructions*
Have you listed accurate names, dosages, and administration times/instructions for these medications?*

YesOther
Health Provider Information
Health Insurance Company*
Health Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Phone*
Please enter a valid phone number.
Name of Insured*

First NameLast Name
Employer*
Policy Number*
Policy number for camper (if different)
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.
Statement of Consent and Authorization for Treatment
For Parent/Guardian
I hereby give consent for the following:

The child listed above may be transported by the Laurelville Retreat Center, PKF and Laurelville Retreat Center staff, including for the purposes of obtaining emergency medical care, to and from Laurelville Retreat Center facilities and other locations used by the PKF and its related entities; the child listed above may participate in mud activities; pictures and videos of the child listed above may be taken in conjunction with Laurelville Retreat Center and PKF activities and events, and the images taken and such child’s likeness may be used in Laurelville Retreat Center and PKF promotional materials. I agree that I and the child listed above will abide by camp rules.

I, on behalf of myself and the child listed on this form, understand that we may be involved in activities, including but not limited to, team building, academic and religious activities, playing with toys and other games, playing on playgrounds, fields, courts, and other recreational areas, running, tumbling, gymnastics, hiking, swimming and other aquatics, boating, water skiing, canoeing, tubing, horseback riding, kayaking, ropes courses, mountain and BMX biking, arts and crafts, team sports, drama and acting, singing and music, social environments and engagement with other youth, preparing and consuming food, and other educational and physical undertakings and social interactions (the "Activities and Programs"). Please also visit www.pittsburghkidsfoundation.org and the web page for each camp to learn more about the types of Activities and Programs in which your child may participate and/or to which your child may be in close proximity.

I understand that this waiver binds me and my child, as well as my heirs, executors, administrators, legal representatives, and assigns, for the benefit of the PKF, its officers, directors, employees, representatives, funding sources, related entities, volunteers, and/or other agents ("Released Beneficiaries"). In exchange for participation in the Activities and Programs, I agree to the following: (a) I agree to prepare my child to take all safety precautions and to abide by camp rules while participating in the Activities and Programs; (b) I understand that my child may be exposed to both physical and non-physical risks, and I agree that I and my child are voluntarily assuming those risks and participating in the Activities and Programs with knowledge that injury to my child or others, including possibly sustaining severe injuries, and even death, may result; I assume full responsibility for physical and non-physical injuries, illnesses, accidents, including death, to my child; (c) I agree that, in the event that my child is physically injured, emotionally harmed, or otherwise requires emergency care, I hereby give permission to the medical personnel selected by my child’s youth leader, or the Laurelville Retreat Center, PKF and Laurelville Retreat Center staff to give routine non-surgical care, order x-rays, routine tests and treatment, to release any records necessary for insurance purposes and to provide or arrange related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by my child’s youth leader, or the Laurelville Retreat Center and PKF staff to secure and administer treatment, including hospitalization, for the person named above. The completed forms may be photocopied for trips out of camp. I release the Released Beneficiaries from all liabilities for all damages, expenses, claims, judgments, actions or causes of action as a result of any loss or injury, to person or property, which I or my child may sustain or suffer during or arising out of participation in the Activities and Programs, whether or not caused by the Released Beneficiaries, and any related medical/allergic conditions.

My signature below affirms that I have read this document, understand it, and agree that it will be binding on me and my child.
By signing my name in the box below, intending for it to serve as my electronic signature hereto, I affirm that I am the legal parent/guardian of the student, have read this entire Health Consent and Release Form, understand it, and agree that it will be binding on my child and me.*

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For Adult Leader
I hereby give consent for the following:

I may be transported by the Laurelville Retreat Center and PKF staff, including for the purposes of obtaining emergency medical care, to and from Laurelville Retreat Center facilities and other locations used by the PKF and its related entities; I may participate in mud activities; pictures and videos may be taken in conjunction with Laurelville Retreat Center and PKF activities and events, and the images taken and such likeness may be used in Laurelville Retreat Center and PKF promotional materials. I agree that I will abide by camp rules.

I understand that I may be involved in activities, including but not limited to, team building, academic and religious activities, playing with toys and other games, playing on playgrounds, fields, courts, and other recreational areas, running, tumbling, gymnastics, hiking, swimming and other aquatics, boating, water skiing, canoeing, tubing, horseback riding, kayaking, ropes courses, mountain and BMX biking, arts and crafts, team sports, drama and acting, singing and music, social environments and engagement with other youth, preparing and consuming food, and other educational and physical undertakings and social interactions (the "Activities and Programs"). Please also visit www.pittsburghkidsfoundation.org and the web page for each camp to learn more about the types of Activities and Programs in which you may participate and/or to which you may be in close proximity.

I understand that this waiver binds me, as well as my heirs, executors, administrators, legal representatives, and assigns, for the benefit of the PKF, its officers, directors, employees, representatives, funding sources, related entities, volunteers, and/or other agents ("Released Beneficiaries"). In exchange for participation in the Activities and Programs, I agree to the following: (a) I agree to prepare myself to take all safety precautions and to abide by camp rules while participating in the Activities and Programs; (b) I understand that I may be exposed to both physical and non-physical risks, and I agree that I am voluntarily assuming those risks and participating in the Activities and Programs with knowledge that injury to me or others, including possibly sustaining severe injuries, and even death, may result; I assume full responsibility for physical and non-physical injuries, illnesses, accidents, including death, to myself; (c) I agree that, in the event that I am physically injured, emotionally harmed, or otherwise requires emergency care, I hereby give permission to the medical personnel selected by my trip leader, or the Laurelville Retreat Center and PKF staff to give routine non-surgical care, order x-rays, routine tests and treatment, to release any records necessary for insurance purposes and to provide or arrange related transportation for myself. The completed forms may be photocopied for trips out of camp. I release the Released Beneficiaries from all liabilities for all damages, expenses, claims, judgments, actions or causes of action as a result of any loss or injury, to person or property, which I may sustain or suffer during or arising out of participation in the Activities and Programs, whether or not caused by the Released Beneficiaries, and any related medical/allergic conditions.

My signature below affirms that I have read this document, understand it, and agree that it will be binding on me.
By signing my name in the box below, intending for it to serve as my electronic signature hereto, I affirm that I have read this entire Health Consent and Release Form, understand it, and agree that it will be binding on me.*

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PKF Camps Policies
Early Release/Pickup Policy

For the safety of each camper, it is our policy to release a camper early from camp ONLY to the individuals listed below as "Trusted Individuals."
Use Emergency Contacts as Trusted Individuals?*

YesNo (enter new Trusted Individuals)
Trusted Individual 1 Name*

First NameLast Name
Trusted Individual 1 Phone*
Please enter a valid phone number.
Trusted Individual 1 Relationship to Camper*
Trusted Individual 2 Name*

First NameLast Name
Trusted Individual 2 Phone*
Please enter a valid phone number.
Trusted Individual 2 Relationship to Camper*
Camper Dismissal Policy
Procedure Protocol: The camp rules are explained up front. If the participant is caught breaking the rules, procedures are explained. If needed, parents will be called. If parents are not reached, emergency contacts will be called. Inability to reach the parents will not hold up sending the participant home. Parents/guardians are financially responsible for the participant and the escort accompanying the student home.

Participants will be dismissed and sent home at the parents’ expense if:
- Participant uses illegal drugs, alcohol, or tobacco during the trip.
- Participant fails to observe other rules and boundaries made clear by the trip leader or violate state or federal law.
- Participant performs any act that endangers others or that the camp management determines unacceptable.
I have read the dismissal and release policies and agree to their terms.*

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Dismissal Policy
Procedure Protocol: Rules are explained up front. If a person is caught breaking the rules, procedures are explained and trip leader is notified.

Participants will be dismissed and sent home at their expense if:
-Participant uses illegal drugs, alcohol, or tobacco during the trip.
-Participant fails to observe other rules and boundaries made clear by the trip leader or violate state or federal law.
-Participant performs any act that endangers others or that camp management determines unacceptable.
I have read the dismissal policy and agree to its terms.*

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Assumption of Risk and Waiver and Release of Liability Agreement
This Assumption of Risk and Waiver and Release of Liability Agreement ("Agreement") is entered into in consideration of Your use of Pittsburgh Kids Foundation property, including but not limited to any Laurelville Retreat Center facilities (the "Premises") and participating in activities and programs on the Premises, whether or not sponsored by Pittsburgh Kids Foundation. This Agreement also covers any programs or activities facilitated by Pittsburgh Kids Foundation off of the Premises (“Offsite Programs”).

You (and references to "you," "your" and "yourself") in this Agreement includes yourself and your family, including any minor children, and any member of your group staying with you.

Assumption of Risk

By signing this Agreement, you:

Acknowledge, understand, and agree that you voluntarily chose to be on the Premises and participate in any programs hosted, sponsored, or organized by Pittsburgh Kids Foundation on the Premises, or that you are voluntarily participating in an Offsite Program.

Waiver and Release of Liability Agreement

This Waiver and Release of Liability Agreement ("Agreement") is entered into in consideration of Your use of Pittsburgh Kids Foundation property, including but not limited to any Laurelville Retreat Center facilities (the "Premises") and participating in activities and programs on the Premises, whether or not sponsored by Pittsburgh Kids Foundation. This Agreement also covers any programs or activities facilitated by Pittsburgh Kids Foundation off of the Premises (“Offsite Programs”).

You (and references to "you," "your" and "yourself") in this Agreement includes yourself and your family, including any minor children, and any member of your group staying with you.

Waiver and Release of Liability

In consideration of being permitted access to Laurelville Retreat Center Premises, Pittsburgh Kids Foundation Programs, or Offsite Programs, by signing this Agreement you also agree to:

Waive and release Pittsburgh Kids Foundation (and its respective directors, officers, employees, volunteers, representatives, agents, and successors and assigns) (the "Releasees") from any and all liability, for any and all loss, damage, injuries, claims, demands, expenses, lawsuits, actions, and or causes of action, that You or anyone on either Your behalf or on behalf of any member of Your group, may hereafter have against Releasees for loss or damage of any kind (including personal injury, illness, disability, and/or death) which occurs while on the Premises or participating in activities on the Premises or an Offsite Program except to the extent caused by the gross negligence or intentional misconduct of such Releasee(s).

You further agree to hold harmless, indemnify and reimburse the Releasees from any and all claims, liabilities, damages, demands, expenses, lawsuits, actions or causes of actions of every kind, nature and character, including but not limited to claims for personal, injury, death, property damage, or any other loss that may result from your visit to the Premises or an Offsite Program to the extent caused by any action, inaction or omission taken by you, including as a result of your negligence, gross negligence or intentional conduct or misconduct. This means you agree to reimburse the Releasees if anyone makes a claim against any of them based on damages or injuries caused by any action, inaction or omission taken by you, including as a result of your negligence, gross negligence or intentional conduct or misconduct.

You also expressly agree that this Waiver and Release of Liability Agreement is intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania, and/or any other state's laws under which this Agreement may be construed and that if any portion of this Agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I have read this Assumption of Risk, Waiver, and Release of Liability Agreement and voluntarily and knowingly agree to all its terms. I also understand that by signing below, I assume the risk for and am waiving all claims against Pittsburgh Kids Foundation for personal injuries or other damages arising from my being granted access to the Premises or participating in activities on the Premises or in an Offsite Program.*

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Today's Date*

MonthDayYear
Date
Should be Empty:

Example Group 2024 Mud Weekend - Complete Paperwork

Your information

Camper's Information

Emergency Contacts

Health History, Medication, & Health Insurance Information

Camper's Health History

Information about dietary restrictions

Health History

Information about dietary restrictions

Medications

Health Provider Information

Statement of Consent and Authorization for Treatment

For Parent/Guardian

For Adult Leader

PKF Camps Policies

Early Release/Pickup Policy

Camper Dismissal Policy

Dismissal Policy

Assumption of Risk and Waiver and Release of Liability Agreement