Emergency and Medical Information
Person to be contacted in case of illness, accident, emergency, and authorized to remove the child from the facility in the absence of a parent/guardian.
To be eligible for camp scholarship all children must be:
- Residents of Duval County (only)- Rising 5th graders through rising 8th graders
Special Needs/Special Education
- A form from a school with the child’s name and current school year/date- A current diagnosis report from a medical or psychological professional verifying the child would require an IEP if enrolled in public schools- A McKay Scholarship letter or form with child’s name and current school year/date
National School Lunch Program
- Report card showing attendance at a school participating in the Community Eligibility Provision (CEP)- Income based free/reduced lunch-quality letter from child’s school- A current copy of Step Up For Students Scholarship letter- Verification household family income does not exceed 185% of the Federal Poverty Level
Informed Consent and Acknowledgement
General Release of Liability: In consideration of being allowed to participate in any way in the GirlsTech STEM Summer Camp program and related events and activities the undersigned agrees to the following: I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions or negligence, but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter is physically fit to engage in the activity in question. I understand that GirlsTech, Inc. and their employees and agents will exercise reasonable care while my daughter is in their custody and care engaging in activities through the GirlsTech STEM Summer Camp Program. I agree to hold GirlsTech, Inc. and its employees and agents harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter for personal injury or illness that may be suffered or any loss of property that may occur to my daughter while participating in the GirlsTech STEM Summer Camp Program.
Medical Release and Authorization
As Parent and/or Guardian of the named camper, 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 significant accidental injury, I understand that every attempt will be made by the attending physician 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 GirlsTech, Inc. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.
Release authorized on the dates and/or duration of the registered season.
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 life and limb of the named minor child, in my absence.
Fees will be paid through PayPal and must be completed in order to complete the registration process. YOU DO NOT need to have a PayPal account to use this system. You can pay by credit or debit card.
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.