Mighty Movers Summer Camp Agreement & Waiver Form

Mighty Movers Summer Camp is a 3-week holistic enrichment program for keiki ages 2-12 created and led by certified Pediatric Physical Therapists here in Hilo, HI. Every Friday for 3 weeks, your keiki will participate in activities to promote overall strength, sensory integration, endurance, etc. Activities can include, but are not limited to: obstacle courses, yoga, dance parties, core circuits, sensory play, bubbles, and more! We would love to have you join us this summer and collaborate with you to promote the overall wellness and enrichment of your child.

Mighty Movers Summer Camp by Made to Move Pediatric Physical Therapy is sponsored by Hawaii

Wellness Mobility Network, Inc. Hawaii Wellness Mobility Network is dedicated to making a meaningful difference in the lives of children and adults with special needs, particularly in rural and underserved communities. We recognize that access to quality care can be limited in these areas, and we are committed to expanding our reach to ensure that everyone, regardless of location, can benefit from essential therapy services, nutritional education, and innovative movement programs that celebrate their unique abilities. To learn more about how you can help or what Hawaii Wellness Mobility Network can support you, please visit our website: https://www.hwmnohanasupport.com/.

• I understand this camp is not a substitute for one-on-one pediatric physical therapy services.
• I acknowledge that this camp is not covered by insurance and is a cash-pay program.

• I understand this is a cash-pay program. I agree not to submit or seek insurance reimbursement for these fees, whether directly or via superbill. No part of this program will be billed to any health plan.
• I understand that this program is for educational and enrichment purposes only and is not part of a medically necessary treatment plan.
• I understand the group nature of the program and that individualized therapy goals will not be addressed. I understand that no documentation will be submitted to insurance or third-party payers on behalf of this program.
• This program is educational in nature and is intended to provide physical activity and developmental enrichment for children ages 2-12.
• It is not intended to diagnose, treat, or replace any medical condition or therapy.
• Parents/guardians are encouraged to consult with their childʻs pediatrician if they have any medical concerns prior to participation.
• The staff and program providers are not responsible for any adverse medical reactions or undiagnosed conditions that may be affected by participation.
• Parents/guardians are responsible for informing staff in advance of any allergies, medical conditions, or specific needs their child may have.

Made To Move Informed Consent and Liability Release Form Mighty Movers Summer Camp Sponsored by Hawaii Wellness Mobility Network, Inc.

Made To Move Pediatric Physical Therapy provides consults for injury, pre-injury, and post-injury education, warm-ups, and activities for individuals and families focused on balance, coordination, and strength. The purpose of these services is to assist individuals in improving their physical well-being and mobility. It is important to understand the risks involved and to cooperate fully throughout the process.

Nature of Services: Our aim is to provide you with consultations, educational guidance, and exercises that focus on enhancing balance, coordination, and strength. These activities may involve physical movements, exertion, and varying levels of difficulty.

Participation: We encourage your full cooperation and active participation in the recommended exercises and activities. Your safety and well-being are our top priorities, so if you ever feel uncomfortable, experience pain, or simply want to take a breather, you have the right to do so.

Risks: It's essential to acknowledge that physical activities come with inherent risks, such as potential discomfort, pain, or the exacerbation of existing conditions. While we take precautions to ensure your safety, please communicate any concerns or limitations you may have.

Medical Consultation: If you have any pre-existing medical conditions or concerns, we recommend consulting with your physician or a qualified healthcare professional to ensure that participating in our dance program is suitable for you.

By signing below, you affirm:

• You have read and understood the nature of the services provided by Made To Move Pediatric Physical Therapy.
• Your participation in these services and activities is voluntary and at your own risk.
• You release Made To Move Pediatric Physical Therapy, including its therapists, employees, and representatives, from any responsibility or liability for injuries or exacerbation of existing conditions that may occur during or as a result of your participation.
• You acknowledge your right to stop or refuse any exercise or activity that you find uncomfortable or painful.
• You consent to the use of any photographs or videos taken of you for marketing purposes by MTM, including but not limited to usage on their website and across various platforms.
• Food Allergies and Preferences: You agree to disclose any food allergies or preferences below to ensure accommodations are made as necessary:

Additionally, you authorize the release of relevant medical information to appropriate third parties, as necessary for the provision of our services.

Please sign below to indicate your understanding and agreement with the terms outlined above.

Mighty Movers Summer Camp Sponsored by Hawaii Wellness Mobility Network, Inc.

Made To Move Pediatric Physical Therapy, in partnership with Hawaii Wellness Mobility Network, Inc., is offering the Mighty Movers Summer Camp—a one-of-a-kind pediatric movement experience on

Hawaiʻi Island. This enrichment-based camp is led by pediatric physical therapists and includes themed stations designed to support coordination, strength, and sensory development.

To help share the story and impact of this unique program, we may request to take photos and video clips during camp sessions to highlight the fun, growth, and movement happening each day.

This is a non-therapy, enrichment-based program that includes creative, movement-based stations: gross motor play, sensory integration, fine motor development, and expressive dance. It is cash-pay and not billed through insurance. Activities are designed to be engaging, developmentally supportive, and inclusive.

By signing this form, you agree to the following:

• Photo and Video Recording: You give permission for your child (and/or yourself) to be photographed or recorded during the Mighty Movers Summer Camp sessions.
• Use of Media: You authorize both Made To Move Pediatric Physical Therapy and Hawaii Wellness Mobility Network, Inc. to use the images and videos for educational, outreach, and marketing purposes. This may include social media, websites, printed flyers, presentations, and future promotions of similar programs.
• Voluntary Participation: You are not required to give photo/video consent in order for your child to participate in the camp. You may opt out by notifying the staff in writing, and your keiki will still be fully welcome to enjoy all the activities.

By signing below, you acknowledge that you have read and understood the above and consent to the use of photos and/or video footage as outlined.

Full payment is due at registration to reserve your child’s spot. Payments are non-refundable unless Made to Move PT cancels the camp.