OFFICE USE ONLY RECEIVED Date: ____________ Time: ________ SAFE ROUTES TO SCHOOL CAMP AT KHES AUGUST 8 - AUGUST 11, 2016 REGISTRATION FORM Return to KHES main office between hours of 8:30 AM – 4:00 PM. You will be notified by of your child’s acceptance on or before June 16. CHILD’S INFORMATION CHILD’S NAME: BIRTH DATE: GENDER: MALE FEMALE ADDRESS: CITY: ZIP: SCHOOL: GRADE (ENTERING 8/2016): FAMILY INFORMATION (CHILD WILL BE RELEASED TO PARENTS/GUARDIANS LISTED BELOW) MOTHER/GUARDIAN’S NAME: HOME #: WORK #: MOBILE #: PAGER #: E-MAIL ADDRESS: FATHER/GUARDIAN’S NAME: HOME #: WORK #: MOBILE #: PAGER #: E-MAIL ADDRESS: EMERGENCY INFORMATION EMERGENCY CONTACT AND THOSE APPROVED TO PICKUP (WRITTEN NOTICE MUST BE PROVIDED BY PARENT/GUARDIAN IN ORDER FOR CHILD TO BE RELEASED TO SOMEONE OTHER THAN PARENT/GUARDIAN): NAME: RELATIONSHIP TO CHILD: HOME #: WORK #: MOBILE #: PAGER #: OTHERS APPROVED TO PICK UP CHILD: _________________________________________________________ CHECK ALL THAT APPLY AND PROVIDE DETAIL WHERE NECESSARY: ALLERGIES (TYPE): MEDICATIONS: YES NO ________________________________________________________________ SPECIAL CIRCUMSTANCES: ___________________________________________________________________ Page 1 of 3 GENERAL CHILD WAIVER AND RELEASE I, the undersigned, for and in consideration of the privilege of having my child participate in the Safe Routes to School Camp do voluntarily waive and release Vidant Health and The Outer Banks Hospital, each of its successors, assigns, affiliates, each of its officers, directors, agents and employees from any liability for any and all claims or causes of action I, my heirs, executors and administrators might now or hereafter have for injury, loss, damages, or death arising out of or as a consequence of or incident to his/her involvement, or as a result of the ordinary negligence of any party. The sole and exclusive purpose of this activity is to provide an experiential learning opportunity for campers, and all activities will be carried out at such times and only in such areas as are specifically approved for such use. I certify that his/her physical condition is such that he/she is able to safely participate in these activities and further certify that he/she has informed Vidant Health and The Outer Banks Hospital to any medical/physical problems or limitations he/she may have. We have also consulted with his/her physician concerning any medical condition(s) and his/her participation in any exercise or activity associated with the camp. I understand the risks involved in these activities and that he/she is a voluntary participant. I understand and agree that the said privilege is contingent upon my executing this release and my compliance with all policies. I have given this information voluntarily, and to the best of my knowledge truthfully and completely. CHILD PICTURE WAIVER AND RELEASE I herby give permission to Vidant Health, The Outer Banks Hospital, Kitty Hawk Elementary School and the Towns of Kitty Hawk and Southern Shores to prepare, use, reproduce, publish, exhibit my child’s name, picture, portrait, likeness, or voice, or any or all of them for use by the news media, the school, and hospital in their public relations, marketing and educational program. Any photograph, photo transparency, drawing or other illustrative graphic material, audio-visual illustration may be used without my prior examination of the finished product. I hereby waive my rights to privacy in connection with consent above given and I herby release, discharge, and agree to held harmless all the parties to whom this consent is given from any liability whatsoever and agree that this consent and waiver will not be made the basis of a future claim. AGREEMENT TO PARTICIPATE Participation in recreational activities involves certain inherent risks and, regardless of the care taken, it is impossible to ensure the safety of the participant in all situations. A variety of injuries may occur to a participant while engaging in walking, riding bikes, and playing on the playground. Minor injuries ranging from muscle, ligament and/or tendon sprains/strains and bruises, to more serious injuries and/or events including death. I, ___________________________________ understand the above and agree that my child and I will follow all camp rules, regulations and requirements. I, ___________________________________ certify that my child possess a sufficient degree of physical fitness to safely participate in the activities and I know, understand and appreciate the risks associated with participation in these activities, and my child is voluntarily participating in the activity. In doing so, I am assuming all of the inherent risks of any and all activities in which my child participates. I further understand that in the event of a medical emergency, management will call EMS to render assistance and that the parent/guardian will be financially responsible for any expenses involved. ADULT PICTURE WAIVER AND RELEASE I herby give permission to Vidant Health, The Outer Banks Hospital, Kitty Hawk Elementary School and the Towns of Kitty Hawk and Southern Shores to prepare, use, reproduce, publish, exhibit my name, picture, portrait, likeness, or voice, or any or all of them for use by the news media, the university, and hospital in their public relations, marketing and educational program. Any photograph, photo transparency, drawing or other illustrative graphic material, audio-visual illustration may be used without my prior examination of the finished product. I hereby waive my rights to privacy in connection with consent above given and I herby release, discharge, and agree to held harmless all the parties to whom this consent is given from any liability whatsoever and agree that this consent and waiver will not be made the basis of a future claim. TRANSPORTATION WAIVER I, the undersigned, hereby consent to and request that my child be transported per the event plans/itinerary by means of a vehicle for the purposes of attending a planned event. In consideration of the privilege of having my child, the above named participant, do voluntarily waive and release Vidant Health and The Outer Banks Hospital and each of its successors, assigns, affiliates, officers, directors, agents, and employees from any liability for any and all claims or causes of actions I, my child, my heirs, executors and administrators might now or hereafter have for injury, loss, damages, or death arising out of or as a consequence of or incident to the above referenced transportation. I understand and agree that transportation will be provided contingent upon my executing this release of liability. I have carefully read this Transportation Waiver and understand its contents and significance and execute it voluntarily. PARENT/GUARDIAN NAME (PRINTED) RELATIONSHIP TO CHILD/PARTICIPANT PARENT/GUARDIAN SIGNATURE & DATE Page 2 of 3 BEHAVIOR EXPECTATIONS AND DISCIPLINE POLICY It is important that camp staff maintain good order and discipline in all programs. The goal of the Vidant Health/The Outer Banks Hospital programs is to safely and effectively provide a positive atmosphere for learning and developing healthy behaviors. Camp staff will make every effort to help children understand clear definitions of acceptable and unacceptable behavior. A child’s behavior is expected to be consistent with Behaviors which may result in immediate dismissal the following: include but are not limited to: 1. Use appropriate language at all times. 1. Any action that could threaten or pose a direct 2. Cooperate with staff and follow directions. threat to the physical/emotional safety of the 3. Respect other children and staff, equipment and child, other children or staff. facilities, and yourself. 2. Prohibited conduct may include, but is not 4. Maintain a positive attitude. limited to, abusive jokes, insults, slurs, threats, 5. Stay in program areas. name calling, bullying or intimidation. 3. Fighting The Discipline Policy 4. Possession of a weapon of any kind or anything 1. If a child is unable to comply with the behavior used as a weapon expectations, an incident report will filled out and 5. Vandalism or destruction of KHES property or the parent will sign a copy and receive a copy. property of others 2. If the child is continuously unable to comply with 6. Sexual misconduct the behavior expectations, camp staff supervisors 7. Possession of or use of alcohol or controlled will hold a conference with the substances unless under the prescription of a parent(s)/guardian. doctor 3. If the child’s behavior continues to be disruptive 8. Running away and/or unsafe, the child will be subject to 9. Biting suspension or dismissal. 10. Inappropriate physical contact/behavior towards a 4. Failure of the parent(s)/guardian to attend staff member or participant conference(s) and cooperate will subject the child to suspension or dismissal. Vidant Health/The Outer Banks Hospital does not This camp aligns with Kitty Hawk Elementary condone and will not permit: School’s S.O.A.R. expectations. 1. Corporal punishment Stay safe 2. Ridiculing, threatening, using an inappropriate Offer help loud voice Act responsibly 3. Leaving children unsupervised Respect themselves and others 4. Use of profanity Special Circumstances Parents/Guardians are required to inform Vidant Health/The Outer Banks Hospital in writing, prior to a child’s acceptance to participate in camp, of any special circumstances that may affect the child’s ability to participate fully and within the guidelines of acceptable