Wright Stuff Summer Camp

ENROLLMENT FORM

This enrollment form must be complete before the child may attend any Wright Stuff Camps.

Enrollment Date: ___________________________

Child's Full Name ___________________________________ Nickname _________________

Date of Birth: ______________ Age ______ Gender _________

Physical Address: ___________________________________________________________

Billing Address: ____________________________________________________________

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Mother/Guardian: __________________________________ Home Phone: _______________

Home Address: ____________________________________ Cell/Msg. Phone: _____________

E-mail address: ________________________________________________________________

Employer: _________________________________________ Work Phone: _______________

Employer's Address: ____________________________________________________________

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Father/Guardian: ___________________________________ Home Phone: ______________

Home Address: _____________________________________ Cell/Msg Phone: ____________

E-mail address: ________________________________________________________________

Employer: _________________________________________ Work Phone: _______________

Employer's Address: ____________________________________________________________

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Emergency Contact – Please list someone other than yourself who lives in the area. We will always try to contact you first.

Name: ____________________________________________ Home Phone: _______________

Relationship to child: _______________________________ Cell/Msg Phone:______________

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Acknowledgement of risks and release of claims

This document affects your legal rights. Please read and understand it before signing it.

Participant Name: _______________________________________________ D.O.B. _________________

Parent/Guardian Name: ___________________________________________ D.O.B. _________________

Address: ________________________________________________________________________________

Telephone: Home ___________________________ Work ________________________- Cell _______________________

I ________________________________ as myself or as the parent and/or legal guardian of ______________________________ in consideration of the participation by him, her, or me, in one or more programs of Wright Stuff Community Foundation (hereafter referred to as WSCF), acknowledge, agree, promise, and do hereby release and discharge WSCF, its officers, directors, employees, agents, and all other persons or entitles associated or affiliated with WSCF on behalf of my child, myself, my heirs, assigns, personal representative and estate as follows:

1. ACKNOWLEDGMENT OF RISK. I understand and acknowledge that participation in WSCF programs is voluntary and my child bears or I bear certain known, unknown, and unanticipated risks which could result in injury, death, illness, disease, physical or mental, or damage to him, her, me, to personal property, or to third parties. These risks include at least the following:

(1) the danger associated with any activity in a wilderness area, (2) the effects of strenuous physical activity at high altitudes, (3) exposure to sun or other extreme weather conditions, (4) the, acts, omissions, and negligence of WSCF, (5) acts of other participants in these activities, including WSCF or others, (6) contact with or consumption of plants or cantact with wild or domestic animals, (7) my child’s or my physical condition or his, her, or my acts or omissions, (8) conditions of the roads, trails or terrain, and accidents connected with their use, (9) first-aid, emergency treatment or other services rendered, (10) consumption of rood or drink, (11) risks associated with rock climbing, including, but not limited to, rock falls and equipment failure, (12) risks associated with swimming including, but not limited to, drowning and hypothermia.

I understand that this list is by no means exhaustive and that the consequences of such risks or hazards may be exacerbated due to occurrence in remote places where rescue and medial attention may not be readily available. I also understand that the consequences of occurrence of illness in such remote places will likewise be exacerbated.

2. ACCEPTANCE OF RISKS AND RESPONSIBILITY. Being aware that this activity entails risks or injury to my child or me and a risk of injury to third parties as a result of his, her or my actions, I expressly agree and promise to accept and assume all responsibility and risk for injury, death, illness or disease, or damage to my child, me, or to property, arising from my child’s or my, participation in this activity.

3. RELEASE I release and forever discharge WSCF from any and all liability, claims, demands, actions or rights of action, which are related to, arise our of, or are in any way connected with my child’s or my participation in Wright Stuff Summer Camp, including but not limited to the negligence of WSCF, for any and all injury, death, illness or disease, and damage to my child, me, or to property. I further agree, to hold harmless and indemnify WSCF from all costs, including attorney fees, or from any other costs incurred in connection with claims for bodily injury or property damage which my child or I, may negligently or intentionally cause to other third parties in the course of his, her, or my participation in the WSCF programs.

I further agree, not to sue, assert, or otherwise maintain or assert any claim against WSCF for any injury, death, illness or disease, or damage to my child, me, or to property, arising from or connected with his, her, or my participation with WSCF programs or from any clain asserted against me by third parties.

In signing this document, I fully recognize that if anyone is hurt or property is damaged while my child is or I am engaged with WSCF, neither I nor any other parent of my child, nor my child will have any right to make a claim or file a lawsuit against WSCF, even if they or any of them negligently cause the bodily injury or property damage.

4. ACKNOWLEDGMENT OF EFFECT OF THIS RELEASE AGREEMENT. I understand and acknowledge that by signing this document I have given up certain legal rights and/or possible claims which I might otherwise assert or maintain against WSCF, including specifically, but not limited to, rights arising from or claims for the acts of omissions, negligent in any degree, of WSCF and all other persons or entities affiliated or associated with it.

5. PARTICIPANT INSURANCE BENEFITS AND REPRESENTATION OF PHYSICAL CONDITION. I understand and acknowledge that no major medical insurance benefits will be provided to my child or me. I certify that I have sufficient health, accident and liability insurance to cover any bodily injury or property damage which my child incurs or I incur while participating with WSCF programs and to cover bodily inury or property damage caused to a third party as a result of his, her, or my participation with WSCF. If I have no such insurance, I certify that I am capable of personally paying for any and all such expenses or liability.

6. ENTIRE AGREEMENT. I understand that this is the entire Agreement between myself and Wright Stuff Community Foundation, its officers, directors, employees, agents, and all other persons or entitles associated or affiliated with Wright Stuff, relating to risk or injury to my child or me, to property, or to others, and that it cannot be modified or changed in any way by the representations or statements of any employee or agent of WSCF, or my me.

My signature below indicates that I have read this entire document, understand it completely and agree to be bound by its terms.

X Signature of parent/guardian of participant(s): ____________________________________________ Date: _______________________

Initials of WSCF officer: __________________

NOTE: Failure to sign this document means that your child or you can not participate in any WSCF programs.

AUTHORIZATION STATEMENTS

Name of Child: ______________________________________ Date: ____________________

Authorization for Emergency Care: I give my permission for Prime Time Child Care and/or any of its employees to seek emergency medical treatment for my child when necessary. I understand that efforts to contact parents or guardians listed on this form will be made before any action is taken. I will accept any expenses incurred by the above mentioned emergency medical treatment. I also authorize trained Prime Time Child Care employees to administer basic first aid to my child if needed.

Parent/Guardian Signature: _______________________________________________________

Authorization for Field Trips: I give my permission for my child to go on field trips under the supervision of a Wright Stuff employee, either on foot or by vehicle.

Parent/Guardian Signature: _______________________________________________________

Authorization for Photo Use: I give my permission for photos and the name of my child to appear in newspapers, advertising, or other media.

Parent/Guardian Signature: _______________________________________________________

Authorization for Medication: I give my permission for trained Wright Stuff employees to administer medication to my child. I understand that medication must be provided by myself in its original container. I also understand that a written prescription from my child's doctor is required.

Parent/Guardian Signature: _______________________________________________________

Authorization for Information Sharing: I give my permission for the staff of Wright Stuff Community Foundation to share information in matters related to the health, safety, education and best interests of my child, as well as statistical information required for funding. I herewith release Prime Time Child Care and the Wright Stuff Community Foundation from any and all liability for supplying such information.

Parent/Guardian Signature: _______________________________________________________

FINANCIAL CONTRACT

This agreement is between Wright Stuff Foundation (WSCF) and ____________________________________________________________________

(Parent/Guardian)

Please initial you have read and understand each agreement, sign and date the bottom.

_____ Deposit and Cancellation Agreement

A 25% non-Refundable non-transferable deposit must be included with your registration. Full payment per camp must be received at least 10 days prior to the camp’s start date or you will forfeit your spot. Registrations received prior to May 1^st will receive a 5% discount on the total. Upon receipt of your registration, we will send confirmation with your billing statement. Should a camp be full upon receipt of your registration, we will contact you within 3-5 days to suggest alternative options.

_____ Acknowledgement of Risk Sheet

In addition to your registration, you must submit a signed Acknowledgement of Risk and all other enrollment forms prior to camp participation. You will not be considered registered until all of these items are received.

_____ Tuition Fee Agreement

I agree to pay my child's tuition fees according to the set price for each camp. I understand it is my responsibility to pay in advance for each camp, according to my bill, and am responsible for 100% of the tuition, regardless of illness or other absences.

_____ Parent Expectation and Agreement

I will notify Wright Stuff of any medical conditions, physical challenges, or special needs my child or I may experience while participating in Wright Stuff Summer Camps.

Parent Handbook Policies

I certify that I have read the Parent Handbook and I agree to abide by all policies and procedures contained therein.

Termination Agreement

I agree to notify the administration in writing at least two weeks prior to terminating this contract and removing my child from Wright Stuff Summer Camp, or I agree to pay one week of tuition beyond my child's last day of attendance. If my account is overdue at termination, I understand that WSCF will use my deposit and possibly file a claim to recover costs in small claims court unless a payment agreement is signed within 30 days.

WSCF feels that each camper has the right to be respected and to participate in a safe and positive camp experience. If a camper chooses to ignore behavioral expectations, the staff/leader may contact parents, excuse the camper from camp until he/she agrees to behave, not invite student back for the remainder of the camp session.

I have read and understand these policies

Signed ____________________________________________ Date _______________________

(Parent/Guardian)

Please Print Name ___________________________________