Camp GAIA
Application and Registration
Today's Date:______Date of Child's Birth ______
Name of Child______
Last First M.I.
Address ______City ______Zip ______
Day Camp Child will be attending (please check ONLY ONE):
______Grades 5th and 6th*
Dates: June 19-23, 2017
Times: 9:00 AM – 4:00PM
______Grades 7th and 8th*
Dates: June 26-30, 2017
Times: 9:00 AM – 4:00PM
*Grade the camper will be registered in the upcoming academic school year.
Parent/Legal Guardian Name ______
Address ______City ______Zip ______
Home Ph. ______Work Phone ______Other______
Where employed______
Parent/Legal Guardian Name ______
Address ______City ______Zip ______
Home Ph. ______Work Phone ______Other______
Where employed______
Please give the names of the persons to whom your child may be released:
Name: ______Relationship______Phone # ______
Name: ______Relationship______Phone # ______
Emergency Information: If Parent/ Guardian cannot be reached, who should be contacted in the event of an emergency?
Name______Daytime#______Alternate#______
Do you have a court order/legal document restricting a person’s access to this child?
Yes______No______If yes, please list the name and provide documentation
Name ______Relationship to child ______
Waiver and Release
In consideration of my minor child (“the Camper”) being permitted to participate in the events and activities involved with Camp GAIA, which include activities at the South Brevard Women's Center, Inc. (hereinafter the “Women’s Center”), offsite locations and transportation to and from the Women's Center to these previously agreed upon offsite locations, I agree as follows:
1. I know the nature of the CAMP and the Camper’s experience and capabilities, and believe the Camper to be qualified to participate in the CAMP or enter into restricted areas where the CAMP is conducted. IF I OR THE CAMPER BELIEVE ANYTHING IS UNSAFE, I WILL INSTRUCT THE CAMPER TO IMMEDIATELY CEASE OR REFUSE TO PARTICIPATE FURTHER IN THE CAMP.
2. I consent to the Camper’s participation in the CAMP and/or entry into restricted areas and HEREBY ACCEPT AND ASSUME ALL SUCH RISKS, KNOWN AND UNKNOWN, AND ASSUME ALL RESPONSIBILITY FOR THE LOSSES, COSTS AND OR DAMAGES FOLLOWING SUCH INJURY, DISABILITY, PARALYSIS OR DEATH, EVEN IF CAUSED, IN WHOLE OR IN PART, BY THE NEGLIGENCE OF THE WOMEN’S CENTER AND ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS AND ATTORNEYS (HEREINAFTER COLLECTIVELY REFERRED TO AS THE “RELEASED PARTIES” IN PERFORMING THEIR RESPECTIVE DUTIES.
3. I HEREBY RELEASE, DISCHARGE AND COVENANT NOT TO SUE the “RELEASED PARTIES” sponsors, advertisers, owners, lessors and lessees of the premises used to conduct the CAMP, FROM ALL LIABILITY TO ME, THE Camper, my and the Camper’s personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON ACCOUNT OF ANY INJURY, including, but not limited to, death or damage to property, CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE “RELEASED PARTIES” in performing their duties.
4. If, despite, this release, I, the Camper or anyone on the Camper’s behalf makes a claim against any of the “RELEASED PARTIES” named above, I AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS THE “RELEASED PARTIES” and each of them from ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS, LIABILITY, DAMAGE, OR COST THEY MAY INCUR DUE TO THE CLAIM MADE OR SUIT BROUGHT AGAINST ANY OF THE “RELEASED PARTIES” NAMED ABOVE, ASSERTING NEGLIGENCE ON THE PART OF THE “RELEASED PARTIES” in performing their respective duties.
5. This Release shall be governed by the laws of the State of Florida and any action brought to interpret or enforce this Release shall be brought exclusively in the appropriate state court situated in Brevard County, Florida.
6. The Women’s Center has my permission to use photographic images of my child, including her first name and age, for public relations purposes as deemed appropriate.
7. I sign this agreement on my own behalf and on behalf of the Camper. I HAVE READ THIS PARENTAL CONSENT, RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, UNDERSTAND THAT BY SIGNING IT I GIVE UP SUBSTANTIAL RIGHTS I AND/OR THE Camper WOULD OTHERWISE HAVE TO RECOVER DAMAGES FOR LOSSES OCCASIONED BY THE “RELEASED PARTIES” FAULT, AND SIGN IT VOLUNTARILY AND WITHOUT INDUCEMENT.
Parental Consent for Field Trips or Leaving the Women's Center Premises
I hereby give ______(my child's name) my permission to attend field trips or leave the Women's Center premises for the purpose of attending a program (swimming, field activities, special events) with the Camp GAIA staff or volunteers either by van, bus, or on foot. In addition, I understand that the Women's Center does NOT carry insurance coverage on vehicles used for the camp beyond the required liability amounts.
Campers are to wear appropriate clothing for physical activity and comfortable CLOSED toe walking shoes. Swim suits and towels will be needed for one day which will be announced on the first day of camp. Also let us know of and any special needs for sun and/ or bug protection.
Please have your camper bring any required medication with clear dosage instructions!
THIS IS A RELEASE – READ BEFORE SIGNING
Parent/Legal Guardian signature ______Date ______
Parent/Legal Guardian signature ______Date ______
Please Provide Us Any Important Medical or Behavioral Information About Your Child That We Need to Know
Medical (if applicable)
Please circle the following items that apply, past or present, regarding your child’s health history.
3
Dietary Restrictions
Down Syndrome
Asberger’s Syndrome
ADHD
Diabetes
Heart Condition
Asthma
High Blood Pressure
Epilepsy/Seizures
Visual Impairment
Cerebral Palsy
Mental Illness
Hearing Impairment
Heat Stroke/Exhaustion
Allergies
ٱLearning Disability
Mental Retardation
Spina Bifida
Other (please specify below):
______
Please provide detailed information to above circled items (If applicable):
______
Behavioral (if applicable)
What kind of task instruction/assistance does child need?
_____ Independent (no additional prompts or instructions)
_____ Prompts needed
_____ One-On-One Support Required
_____ Uses an assistive device, explain:______
What is child’s primary means of communication?
_____ Speaks, understood by others
_____ Speaks, difficult to understand
_____ Sign language
_____ Non-Verbal
_____ Other. Please explain:______
If applicable, check behaviors that are a concern.
_____ Withdrawn/shy
_____ Easily discouraged
_____ Harms others/self
_____ Short attention span
_____ Manipulative
_____ Runs away
_____ Hyperactive
_____ Other. Please explain:______
Describe best ways to manage behavior(s)______
How does child interact with others?______
Are there any limitations that could prohibit your child from participating in certain activities (such as swimming, walking long distances)?
______
Any other information that you would like to share about your child?______
______
Parental Agreement
I, ______(parent/guardian), in consideration of the acceptance of
______(child’s name) as a Camp GAIA day camper, hereby agree
to comply with the terms stated in the Camp GAIA application and brochure.
______
Signature Date
Payment
Please mail this 4-page, fully completed application with a check or money order for $25.00 (or $125.00 if you wish to pay the camp fees in full) to:
The Women's Center
ATTN: Camp GAIA
1425 Aurora Road
Melbourne, FL, 32935
*You may pay for the camp with a credit card by stopping by the Women's Center reception desk or at www.womenscenter.net
I understand there will be NO refunds of day camp fees unless the program or activity is canceled by the Women' Center.
** Initial ______
NOTE: The $25 registration fee must accompany this fully completed application. Payment of the registration fee will hold a place in the camp for your child and will apply towards the $125 camp tuition. Payment in full is due one week from the session start date.
· Payment due date for Grades 5th and 6th Camp, June 14, 2017
· Payment due date for Grades 7th and 8th Camp, June 21, 2017
Failure to pay by the payment due date will result in loss of the camper's reserved spot and loss of the $25 registration fee.