Survival Rockport 2019 Youth Registration Form
Please complete this form immediately after paying for your spot in Survival Rockport Camp
Survival Rockport Session # *
Required
Child First Name *
Your answer
Child Last Name *
Your answer
Child Date of Birth *
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DD
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YYYY
Age *
Child Gender *
Will this camper need a daily ride to and from Kestrel's downtown Beverly office? (Note: This is a new option and dependent on a minimum of 3 campers requesting rides on any given week. Maximum of 6. We can transport between 3 and 6 campers. $65 per week extra for rides)
Parent-Guardian Information
Parent-Guardian Name 1 *
Your answer
Phone number *
Your answer
Email *
Your answer
Street Address *
Your answer
City or Town
Your answer
State
Your answer
Zip Code
Your answer
School Attending and Grade Entering Next Fall (Or specify homeschooled)
Your answer
Parent-Guardian Name 2
Your answer
Phone number
Your answer
Email
Your answer
Street Address
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 or Behavioral Condtitions
Physician *
Your answer
Physicians Address *
Your answer
Physicians Phone Number *
Your answer
Health Insurance Company *
Your answer
Policy # *
Your answer
Vaccination History
We are required by law to collect vaccination records for our participating campers. We will need you to provide evidence of each of the following types of immunizations.
(1) Measles, Mumps and Rubella (MMR) Vaccine: A minimum of one dose of MMR vaccine(s)must be administered at or after 12 months of age. A second dose of live measles-containing vaccine given at least four weeks after the first, is required for all campers and staff, who will be entering grades K-12 or college in the school year immediately following the camp session (or incase of an ungraded classroom or the camper/staff does not attend school/college, campers or staff five years of age or older). Laboratory evidence of immunity is acceptable. *
(2) Polio Vaccine: A minimum of three doses of either inactivated polio vaccine (IPV) or oral polio vaccine (OPV) are required. If a mixed (IVP/OPV) schedule was used, four doses are required. *
(3) Diptheria and Tetanus Toxoids and Pertussis Vaccine: A minimum of four doses ofDTaP/DTP/DT or at least three doses of Td is required. Where a camper or staff person is seven or more years of age and requires additional immunizations to satisfy 105 CMR 430.152(A)(3),Td is to be substituted for DTaP, DTP or DT vaccine. Effective January 1, 2004, a booster dose of Td is required for all campers and staff who will be entering grades seven through ten (or in the case of an ungraded classroom or the camper or staff does not attend school, campers or staff 12 through 15 years of age) if it has been more than five years since the last dose of DTaP/DTP/DT. For all campers and staff who will be entering grades 11 and 12(or in the case of an ungraded classroom or the camper or staff does not attend school, campers or staff16 through 17 years of age) a booster of Td is required if it has been more than ten years since the last dose of DTaP/DTP/DT/Td. *
(4) Hepatitis B: For all children born on or after January 1, 1992, three doses of Hepatitis B vaccine are required. Laboratory evidence of immunity is acceptable. *
Please explain below, any "No" responses to immunization questions
Your answer
Kestrel must receive a copy of current immunization records demonstrating all of the above requirements have been met, please send these documents in as soon as possible. The deadline for immunization records is June 15th. *
I will transfer these records to Kestrel via:
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? *
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
What is your child's skill level in swimming *
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
Important Information *
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 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.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 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 tp to participate in spite 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. 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. I give permission to KEA staff and volunteers, as well as visiting press reporters and members of organizations providing funding, to photograph 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, and the web. 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 program. 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 program. I have carefully read, understand, and voluntarily sign this document. I understand that I am surrendering certain legal rights owned by me and by my child(ren). I hereby warrant that I have legal authority to act on behalf of any child(ren) for whom I have signed this waiver. I agree, on my own and on behalf of the child(ren), to the terms and conditions in this document.
Required
Electronic Signature *
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Additional Information
What are your child/childrens' favorite outdoor activities?
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