Winter Camp Consent Form 2019

1 Session: January 3 - 4

Student Information

Student's Name*

First NameLast Name

Birth Date*

MonthDayYear

What grade will your child be going into in the Fall?*

What school does your child attend?

Student ID #*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name*

First NameLast Name

Home Number

Area CodePhone Number

Cell Number*

Area CodePhone Number

E-mail*

Gender

FemaleMaleOther

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the student prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Shine MSD during the selected camp. In exchange for the acceptance of said child’s candidacy by Shine MSD ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Shine MSD and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Shine MSD including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

By entering your initials in the box below, you are effectively providing your signature*

Initials

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 camper. 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 Shine MSD and its affiliates including Directors, Counselors, and Staff 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 session.

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.

By entering your initials in the box below, you are effectively providing your signature*

Initials

Photography & Media Release:

Please be advised that students and staff may, when appropriate, take photos and video to be used in promotional & educational materials for Shine MSD.

Pursuant to the above, I give permission for images, videos, and recordings of the child to be used in print, video, digital and internet media. I agree that these images and/or voice recordings may be used for a variety of purposes and that these images may be used without further notifying me. I further acknowledge that I will not be compensated for these uses and that Shine MSD owns all rights to the images, videos, and recordings, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release Shine MSD and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

Media Consent*

I WILL permit my child to be photographed, videotaped, and/or interviewed for Shine MSD social media outlets, student videos, promotional materials and/or for other communication toolsI WILL NOT permit my child to be photographed and videotaped for Shine MSD social media outlets, student videos, promotional materials and/or for other communication tools

Artwork Release:

Please be advised that students and staff may, when appropriate, take photos and video of my child's artwork (paintings, drawings, song recordings, dramatic interpretations, etc) to be used in promotional & educational materials for Shine MSD. Shine MSD will always get written consent from the student to photograph any artwork.

Pursuant to the above, I give permission for my child's artwork to be used in print, video, digital and internet media. I agree that these images recordings may be used for a variety of purposes and that these images may be used without further notifying me. I further acknowledge that I will not be compensated for these uses and that Shine MSD owns all rights to the images, videos, and recordings of the artwork, and to any derivative works created from them. I waive any right to inspect the uses of any printed or electronic copy. I hereby release Shine MSD and its agents and assigns from any claims that may arise from these uses, including without limitation claims of defamation or invasion of privacy, or of infringement of moral rights or rights of publicity or copyright.

Artwork Consent*

I WILL permit my child's artwork to be photographed, videotaped, and/or interviewed for Shine MSD social media outlets, student videos, promotional materials and/or for other communication toolsI WILL NOT permit my child's artwork to be photographed and videotaped for Shine MSD social media outlets, student videos, promotional materials and/or for other communication tools

By entering your initials in the box below, you are effectively providing your signature*

Initials

General Information:

How has your child been coping since February 14, 2018? Is there anything you would like us to be aware of or take into consideration?

What shirt size does your child wear?

Confirmation

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.

Electronic Signature of Parent or Guardian

Winter Camp Registration