Camper Information and Payment Authorization Form

 

 

Camper Information and Payment Authorization Form

Required

Camper's Name required
First Name
Last Name
Must contain a date in M/D/YYYY format
Are there any health problems including physical or mental health, or behavioral problems, of which we need to be aware. requiredPlease select up to 1 choice
Please select up to 1 choice
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?requiredPlease select up to 1 choice
Please select up to 1 choice
Must contain a date in M/D/YYYY format
For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?requiredPlease select up to 1 choice
Please select up to 1 choice
Does the camper reside outside the US?requiredPlease select up to 1 choice
Please select up to 1 choice
Attach up to 1 file at a time. File size may not exceed 10MB
No file chosen
The information provided above is accurate. required
Only parents listed on the campers account and emergency contacts are able to pick up campers. If a change to the pick up needs to be made, please email summerknights@smrhs.org. required
Program participants will be required to abide by the SMR Student Code of Conduct while attending the SMR Programs. required
Participant Health Information is required for all program participants and a medical release form may be required based on the survey. A signed Statement of Informed Consent, Assumption of Risk and Release form must be completed and on file prior to participation in these programs. In the event of an emergency, SMR will contact emergency services to arrange transportation to the nearest health-care facility.required
Participants will only be permitted to leave the programs with authorized adults. Photo ID may be required.required
Photograph/video rights are extended with this registration for the purpose of marketing future programs. required
Program fees are payable at the time of registration by credit card. Camper registration is not complete until payment is made. Payment should be completed at the time of registration or the campers registration will be forfeited. required
Program fees will be refunded in full if SMR does not run the program. Programs may be dropped and a refund issued (with the sum being refunded back to your credit card, less a $50 withdrawal fee) until May 31. Program fees will NOT be refunded after May 31, 2021 for any reason.​​​​​​​​​​​​​required
I have read the following Informed Consent and Release of Liability Statements and agree to these conditions: Participation in activities for the Summer Knights Program may involve risk and that the risk will vary based upon the program my child is involved with. • Participation in activities for the Summer Knights Program requires health information to be completed and be accurate and that if, upon further review, medical personnel for SMR deem it necessary, my child may be required to have a medical clearance prior to participating in the activity. • I assume all risks of loss or damage, illness or injury my child might sustain while participating in any Summer Knights Program. Further, I will make no claim against and release, waive, discharge, hold harmless and indemnify, on behalf of myself, my personal representative and my heirs, St. Mary’s Ryken High School and its officers, agents, and employees for any and all claims and causes of action for any injury or loss, or for damages, costs, expenses, or compensation that may occur during or resulting from my child’s participation in this program, whether arising through the negligence, omission, default or other action of any person or event associated with this program, including other participants. • I agree that all disputes, et al that may arise between myself, my personal representative, my heirs and St., Mary’s Ryken High School and its officers, agents, and employees relating to this Statement of Informed Consent, Assumption of Risk and Release, will solely be resolved by arbitration. Except as may be required by law, neither a party nor an arbitrator may disclose the existence, content or results of any arbitration without the prior written consent of both parties. I have read and understand the information above. I grant permission for my child to participate in the Summer Knights Program and grant the informed consent, assumption of risk, and release on behalf of my child and the child’s family.​required
Payment Made Byrequired
First Name
Last Name

Payment Information

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Billing Addressrequired
Cardholder Namerequired