Membership Status

Member

Non-member

Child's First Name

Child's Last Name

Camper's Birthdate

YYYY

Campers must be toilet trained to participate.

I confirm my child is toilet trained.

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone

(###)

###

####

Parent/Guardian Email

Parent/Guardian Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized adults for pickup

Please list all names of authorized adults who are allowed to pick up your child. We will be checking IDs at pickup.

Emergency Contact

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

(###)

###

####

Describe any allergies, medical concerns, or behavioral factors which may impact your child’s participation in this program?

If not applicable, put N/A below.

Will your child require any medication(s) to be kept on-site at Wing Haven (includes Epi-Pen, prescriptions, or over-the-counter drugs)?

If yes, we will contact you for more information.

Yes

Medical Release Agreement

A. I believe the information provided above is a complete and accurate statement of the physical and behavioral factors which may affect my child’s participation in Camp Wing Haven.

Electronic Signature

Medical Release Agreement Cont.

B.) I grant permission for the staff of Wing Haven to take whatever steps necessary to obtain emergency medical care, if warranted. These steps may include, but are not limited to the following: 1. Administer minor first aid 2. Attempt to contact a person, guardian or emergency contact 3. Attempt to contact the child’s physician 4. If we cannot contact the parent or the child’s physician, we will do any of the following: a. Call another physician b. Call an ambulance. c. Have the child taken to the emergency room in the company of a staff member in a staff vehicle. 5. Any expenses incurred under the item “4” above will be borne by the child’s family. C.) I understand & acknowledge that my child’s participation in the activities of Camp Wing Haven are completely voluntary and has familiarized him/her with the activities in which hazards and/or dangers are inherent. D.) While Wing Haven has taken steps to maintain a safe work-play environment, it cannot ensure or guarantee that the equipment, premises and/or activities will be free of hazards, accidents or injuries.

Electronic Signature

I grant permission to Wing Haven staff to administer the following to my child:

Please select all that apply

Topical insect repellent

Sunscreen

Triple antibiotic ointment (scrapes/cuts)

Hydrocortisone cream (insect bites)

Electrolytes (in the form of gatorade, powerade, etc.)

None of the above

Health and Safety Protocols

Wing Haven has developed a set of camp protocols for the safety of all campers, staff, and volunteers. Please read about these safety measures and other procedures online: https://winghavengardens.org/childed_protocols I will follow the requirements stated in the safety protocols when sending my child to camp and understand that if my child is unable to follow the requirements while in camp, I will come pick them up from camp.

Electronic Signature

Photos agreement

Check the box next to your preference below.

I grant Wing Haven, its representatives and employees the right to take photographs of my child in connection with Wing Haven. I authorize Wing Haven, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Wing Haven may use such photographs of my child for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

I DO NOT grant Wing Haven, its representatives and employees the right to take photographs of my child in connection with Wing Haven.

Electronic Signature

Your email confirmation is your receipt. A confirmation letter and release form will be emailed to you mid-May.

Thank you!

Camp Nature Tales Medical Release