Pope Memorial SPCA

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Please list all medication needed during camp hours. Include emergency medications. All medications must be unexpired and in original containers. Prescription medications must include the pharmacy label.

Medical release: This health history is correct and accurately reflects the known health status of the named camper. The camper described has permission to participate in all camp activities except as noted by me and/or their physician. I give permission to camp staff to provide routine health care; to administer prescribed or over-the-counter medications as described; and to provide or obtain emergency care and transportation for the camper if needed. I will also provide a copy of my child's complete immunization records prior to June 1st.

Medications: I authorize Pope Memorial SPCA staff to administer as listed above medications at camp and asthma or allergy emergency medications, as directed, to my child for whom was prescribed. I understand that all medications at camp must be approved, seen and checked by the camper's supervisor, and each dose monitored by a camp staff member. I understand that all medications must be in their original containers, unexpired, and labeled with specific instructions, including the child's name and dosage, and that any prescription medications must include the full pharmacy label.

Insurance: I certify that the named camper is covered by health and accident insurance or Medicaid and that the policy information given is correct.

I, the parent/legal guardian of the named camper, have read, understood, and agree to abide by the terms and policies listed above.

If available, please upload your child's complete immunization records and documentation of their last physical exam; exam must be within two years of start of camp session. If unavailable, please submit by June 1st.

My camper may be released to the following adults — other than parent & emergency contacts (include first and last names):

Parent/guardians may send a note to make changes to this list. People picking up campers must bring a photo ID. If a person not listed above arrives to pick up a camper, the camper will remain with camp staff until the parent/guardian has been contacted and has given permission for the release. If there are specific people to whom the camper may not be released, please inform the camp in writing.

Release/Pick-Up: I, the parent/legal guardian of the named camper, have read, understood, and agree to the release policy as described and authorize Pope Memorial SPCA to release my child to the people listed on this form.

Program: I give permission for my child to participate in all camp program activities. I understand that Pope Memorial SPCA reserves the right to change the program activities or instructors and cancel programs, should Pope Memorial SPCA decide in its sole judgement that it is necessary and appropriate to do so.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Exceptions/Dismissal: I have informed the Camp Director and other appropriate Pope Memorial SPCA staff of any limitations to my child's participation and agree to abide by Pope Memorial SPCA sole judgement as to whether my child can be accommodated in the camp program. I understand that failing to disclose any physical, emotional, or behavioral needs and conditions may result in the child's dismissal from the program without a refund. I understand that my child must follow the stated behavior expectations and safety rules and that Pope Memorial SPCA reserves the right in its sole judgement to dismiss without refund any child whose behavior interferes with the rights and safety of others or consistently disrupts group dynamics or activities.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Animal Interaction: I do recognize that in conjunction with my child's attendance at Pope Memorial SPCA, my child will be in contact with and maybe allowed to hold shelter animals. I understand that despite all precautions made, there is a chance that my child may sustain a scratch or bite while handling these animals. I understand that the above is illustrative of the types of risks involved in participating in the camp program at Pope Memorial SPCA, but is in no way a complete list of possible risks.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

Hygiene Protocols: I understand due to COVID-19 virus and communicable diseases that my child may use hand sanitizer with at least 60% alcohol. Hand sanitizer will be securely used under the supervision of staff/volunteers at all times.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

I also understand I am to follow an at home screening process that involves taking my child's temp prior to attending camp and answering following questions:

If your child has experienced any of the following symptoms within 48 hours prior to the first day of camp, your child may not attend camp.

Any person that develops symptoms while at camp will be removed from the group, and arrangements will be made immediately for your child to be picked up. If your child is sent home from camp with any of these symptoms, they must be symptom-free for 24 hours and obtain a doctor's note before returning to camp.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the above.

I understand and agree to the payment, cancellation refund policies, as listed on Pope Memorial SPCA website and are as follows:

The first $50 paid for each registration is nonrefundable. (If the SPCA must cancel a session, you will receive a refund of all fees paid.) Refunds are not given for dismissal, failure to attend, absence, or sick days. If you cancel before the start of your camp session, the amount of the refund is determined by the following schedule: Before June 1st: all but $50 refunded After June 1st: no refund available

I have read and agree to abide by the terms and policies listed above.

Pope Memorial SPCA photographs and records programs to document the enjoyable and educational experiences children have while working with and learning about animals, and to share these experiences with the community. Children will be identified only by first name and program unless additional written permission is provided.

I am the parent/legal guardian of the named camper and have read, understood, and agree to the terms above.

Pope Memorial SPCA staff members and volunteers make every effort to conduct safe programs, to orient and support children, and to inform families of inherent risks. Some activities may involve risks that children do not routinely encounter at home.

I understand that program activities may include, but are not limited to, active games, interaction with shelter animals, and outdoor activities such as walks on nearby trails.

I acknowledge that such risks exist, and I agree on behalf of my child to assume these risks. Further, on behalf of my child, I release and agree not to hold liable Pope Memorial SPCA of Concord-Merrimack

County, its officers, directors, employees, and volunteers for any injury, illness, or loss that may occur as a result of participation in program activities, except in cases of gross negligence.

I understand that participation in group programs may involve exposure to communicable illnesses. Pope Memorial SPCA follows applicable health and safety guidance to reduce risks; however, exposure cannot be completely eliminated. I accept this risk on behalf of my child.

I understand and agree that my child shares responsibility for following safety rules and staff directions during all activities. Participation in Pope Memorial SPCA programs is voluntary, and I confirm that I am familiar with the types of activities in which my child may participate.

I, the parent/legal guardian of the named camper, have read, understood, and agree to the Acknowledgement of Risk & Assumption of Personal Responsibility and its terms and conditions.