Middle School Conservation Club Registration Spring 2019
Child First Name *
Your answer
Child Last Name *
Your answer
Please explain in 2-3 sentences, what interests you about a club for having adventures and completing projects that will help people and nature.
Your answer
The Conservation Club is about youth-led projects and requires we build a community and design and complete adventures and projects together. Can you commit to coming every week and participating fully?
Child Date of Birth *
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Age *
Child Gender *
Parent-Guardian Information
Parent-Guardian Name 1 *
Your answer
Phone number *
Your answer
Email *
Your answer
Street Address *
Your answer
City and State
Your answer
School Attended Currently
Your answer
Parent-Guardian Name 2
Your answer
Phone number
Your answer
Email
Your answer
Street Address
Your answer
City and State
Your answer
Will your child need pickup from school to get to our club meeting location? If so, please note time and place where you would prefer pickup.
Your answer
Please list the names of all adults who are authorized to pick up your child and/or state that your child has permission to walk to and from the program unaccompanied.
For example Jane Smith, and John Smith
Your answer
Emergency Contact
If parent/guardians can't be contacted this is the next person to be contacted
Emergency Contact Name *
Your answer
Phone number *
Your answer
Medical Information
Physician *
Your answer
Physicians Address *
Your answer
Physicians Phone Number *
Your answer
Health Insurance Company *
Your answer
Policy # *
Your answer
Explanation
Your answer
Does your child suffer from allergies? *
Does your child take any medications? *
Does your child have any dietary restrictions? *
Does your child suffer from a medical, behavioral or mental health condition that may impact participation? *
Has your child ever had major surgery? *
Is your child limited and/or restricted in terms of physical activity? *
If you responded Yes to any of these questions, please tell us more.
Your answer
Health History
Has your child been hospitalized in the last six months? *
Has your child fainted in the last six months? *
Has your child been seriously injured in the last six months? *
Does your child suffer from tuberculosis in a communicable form, or have evidence or symptoms thereof? *
Does your child suffer from a chronic or recurrent illness? *
Does your child suffer from asthma, wheezing or shortness of breath? *
Does your child suffer from diabetes? *
Does your child suffer from seizures? *
Does your child suffer from severe headaches? *
Does your child suffer from chest pain during exercise? *
Does your child wear glasses, contacts or protective eyewear? *
If you responded Yes to any of these questions, please tell us more.
Your answer
Waiver and Release
Rules Agreement *
In consideration of participating in Kestrel Educational Adventures programming, I acknowledge and agree as follows: I have had the opportunity to ask questions about the activities and the risks of the program in which I or my children will participate. I agree to obey all rules, regulations, and policies and agree to have my child(ren) obey them. I agree to provide written notice to KEA of any mental or physical conditions that may make participation in Kestrel programming unsafe.
Required
Activities and Risks *
The activities in which I or my children may participate will depend on the program. These activities may be physically strenuous and may include, but are not limited to: hiking on uneven, rocky, and slippery terrain and in high grass and wooded areas; tree climbing; swimming and wading in fresh water and ocean water; cooking; fire building and use of fire; use of knives and other tools; building and sleeping in natural shelters; rock climbing; backpacking; snowshoeing; interacting with wildlife; and service projects. I understand that they will be traveling a van driven by YMCA or Kestrel instructors. I understand that my child(ren) or I may engage in other activities not described above and that scheduled program activities may be substituted with other activities without prior notice. It is impossible to state every risk associated with KEA program activities; however, I understand the risks I or my child(ren) may encounter include, but are not limited to: slipping; falling; being struck by or striking objects, persons or the ground; wave and tidal action; exposure to sharp objects, both natural and man-made; improper or malfunctioning equipment or structures; exposure to hot, cold, wet, and other potentially hazardous types of weather; hypothermia or hyperthermia (heat-related illness, heat exhaustion), sunburn, and dehydration; distance from comprehensive emergency medical care; physical contact with other participants; and interaction with outside vendors and members of the general public. I acknowledge that the risks involved in participation in the KEA programming, including any risks not herein identified and described, may cause or lead to injury, illness, death, or property damage. These and other risks are inherent to the activities and they cannot be changed or eliminated without altering the essential elements or quality of the activity. I acknowledge and understand that KEA cannot change or eliminate these risks. I acknowledge that my or my child(ren)’s participation in KEA programming is purely voluntary and I elect to to participate in spite of all known and unknown risks. I agree that the Student and I assume the risk of the activities in KEA programming, whether or not described in this form.
Required
Disclosure and Indemnification *
I further acknowledge that I have an obligation to disclose any and all allergies, including drug allergies, and understand Kestrel will withhold the administration of these drugs only if requested by the Parent / Guardian in advance. On behalf of my child(ren) and myself, I hereby forever release, waive, and discharge KEA and each of KEA's agents, affiliates, employees, officers, directors, trustees, independent contractors, volunteers, and all other persons or entities acting under KEA's direction and control (collectively "the Released Parties") from any claim, right, or cause of action, including but not limited to, any claims for injury, property damage, wrongful death, breach of contract, loss of consortium, or any other type of lawsuit, that I or my child(ren) may have arising, in whole or in part, from enrollment or participation in KEA programs, including claims, rights, or causes of action caused by the negligence of the Released Parties. I covenant, promise, and agree not to pursue any claim or lawsuit against the Released Parties, collectively or individually, for any liability, claim, or expense in any way associated with the Student's enrollment or participation in the KEA program or the use of any equipment or facilities owned or operated by any of the Released Parties. I certify that I have adequate insurance to cover any injury or damage caused or suffered while participating in the KEA program, or else I agree to bear the costs of such an injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I or my child(ren) may have that may increase the risks of participation in KEA programs or may increase the magnitude of potential injuries. I further agree to defend and indemnify the Released Parties (to pay or reimburse them for money they are required to pay) for all costs, including attorney's fees and court costs, with respect to any and all claims related to participating in KEA programs.I agree that the substantive law of Massachusetts (but not any law that would apply the laws of another jurisdiction) governs this document and any dispute or lawsuit I or my child(ren) has with the Released Parties. Any mediation, lawsuit, or other proceeding must be filed or entered into only in Massachusetts. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions.
Required
Photography *
I give permission to KEA staff and volunteers, as well as visiting press reporters and members of organizations providing funding, to photograph or video the student, and to use these photographs to promote KEA and its activities. The possible uses of photographs may include (but are not limited to) newspaper or newsletter articles, slide shows, brochures, short films, digital marketing, social media, and the Kestrel website. We do not use student names (first OR last) without express permission from a parent or guardian (we would only use names in very special circumstances such as when a student completes a project and wishes to share it publicly and get credit for it)
Required
Cancellations and Refunds *
I understand that if KEA cancels a program for any reason, I am entitled to a credit or refund worth the full value of the cancelled class or program. I also understand that I am entitled to a credit or refund worth the full value of the class or program when I cancel more than two weeks in advance of the start of the first class or meeting. I further acknowledge that KEA does not offer refunds, rebates or discounts for partial or incomplete attendance, or for cancellations made within two weeks of the start of the first class or meeting. I understand that if my child cannot follow the basic safety rules or decides to withdraw from the program, we cannot offer any refunds or pro rated refunds.
Required
Electronic Signature *
Write your name here
Your answer
Additional Information
What are your child/childrens' favorite outdoor activities?
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