Summer Camp Forms

Step 1 of 4

Child Information

Name *

First

Last

Date of Birth//

Gender

Male
Female

Last completed grade

Name of School

Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Information

Name *

First

Last

Email *

Phone

Parent/Guardian 2 Information

Name

First

Last

Phone

Emergency Contacts

Do not include mother and father

Name *

First

Last

Phone

Relationship

Approved Pickup List

Please list people that may pick up your children

Name

First

Last

Name

First

Last

Name

First

Last

Name

First

Last

Health and Safety

Informed Consent and Acknowledgement *

I hereby give my approval for my child’s participation in any and all activities prepared by Maple Corner during the selected camp. In exchange for the acceptance of said child’s candidacy by Maple Corner, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Maple Corner Montessori 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 Maple Corner Montessori including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities, including swimming. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization *

As Parent and/or Guardian of the named student, 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 athlete. 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 the Maple Corner Montessori and its affiliates including Directors, Coaches, and Team Parents 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 season. 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.

Elementary Swim Waiver

Please Select One *

{Elementary Students} I have no objection to my child participating in swimming activities at the UCC pool during Maple Corner Montessori’s Summer Camp. I acknowledge that my child will be under the supervision of UCC hired lifeguards and MCM camp staff.
{Elementary Students} I do not want my child to participate in swimming activities at the UCC pool. I acknowledge that during this time my child will be provided with an alternate, non-water involved activity either at the school or in the sitting area on the UCC pool deck.
{Primary Students} My child is in Primary and therefore will not be swimming

Signature *

Confirmation BY ACKNOWLEDGING AND SIGNING, 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 AND APPLIES TO ALL TERMS, CONDITIONS AND WAIVERS ENCLOSED IN THIS FORM

Child Information

Parent/Guardian Information

Parent/Guardian 2 Information

Emergency Contacts

Approved Pickup List

Maple Corner Behavior Policy

Photo Release

Refund Policy

Health and Safety

Elementary Swim Waiver