Adventure Camp - Camper Registration Form

RELEASE AND ASSUMPTION OF RISK
Camper Name*

First NameLast Name
Please read the following statement and sign where indicated below

Since La Vida’s beginning in 1970, we have had an excellent safety record. All activities are designed with safety in mind, and standard procedures are strictly enforced by trained staff. The La Vida policy “Challenge by Choice” means that each participant determines the level and extent of their participation. The staff will encourage participants to try each activity but will not use or allow peer pressure to force any participant to do anything they would prefer not to do. Camp activities may have more risk or danger than everyday life. As a result, this Release and Assumption of Risk has been drawn up and must be signed by each participant or the parents of minors.

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I am aware that during La Vida certain risks and dangers may occur which are out of the control of the instructors. I further realize that I will be participating in activities (including high course elements 20-40 feet high and low course elements) in which the risk of an accident may be greater than in my normal way of life.

In consideration of the right to participate in such La Vida activities, I have and do hereby assume all the above risks and will hold Gordon College and the La Vida instructors harmless from all liability, actions, causes of actions, debts, claims and demands of every kind and nature which might arise in conjunction with my participation in La Vida. I also acknowledge the fact that the instructors have the right to terminate my participation in La Vida because of my health or physical condition. I agree that the decision of the instructors shall be binding upon me.
Parent/Guardian Name*

First NameLast Name
Signature of Parent/Guardian*

Clear
Release and Assumption of Risk
Date*

MonthDayYear
Release and Assumption of Risk
Photo Release Statement: The La Vida Center may use any photograph or video footage of me or my child for advertising, art, or promotional purposes. I waive my right to inspect or approve the finished product, and know that I will not receive any compensation for any products used by La Vida.
Photo Release*

I DO give La Vida permission to use photos/videos of this camperI DO NOT give La Vida permission to use photos/videos of this camper

La Vida Adventure Camp Medication Authorization Form

La Vida Adventure Camp will not administer medication or allow campers to self-medicate unless this form is completed by the camper’s parent/guardian and reviewed by the health care consultant at La Vida Adventure Camp.
Camper Name*

First NameLast Name
Camper Age at Time of Camp
Age
Parent / Guardian Name

First NameLast Name
Emergency Contact

First NameLast Name
Relationship
Best number to reach contact
Please enter a valid phone number.
Backup Number
Please enter a valid phone number.
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Massachusetts Regulations Regarding Camper Medication

Please read this text and respond to the sections below.
105 CMR 430.160(A)
Massachusetts regulations regarding camper medication requires prescription medicine be kept in the original containers with the pharmacy label, including date, location, pharmacist, serial number, prescribing physician, name of medicine, directions for use, cautionary statements, and amount of medicine in the container. Over-the-counter medicine must also be kept in original containers with directions regarding use. Medication can only be administered by the camp’s health supervisor or a licensed healthcare professional.

The use of over-the-counter medications is not encouraged and will be limited as much as possible during the program. Medications will be in the possession of La Vida staff and will be administered sparingly and according to manufacturer’s instructions. If a question arises during the program regarding medication, parents will be contacted.
Parent/Guardian initial to acknowledge*
Authorization to Administer Over the Counter Medication

Over the counter medication supplied by Adventure Camp, including hand sanitizer
Please check this authorization and complete the appropriate information below. If this camper does not need other medications, please still complete this form to authorize us to provide hand sanitizer to them.*

I hereby authorize La Vida Adventure Camp to administer to this camper the over-the-counter medications indicated below, in accordance with Massachusetts regulations.I DO NOT authorize La Vida Adventure Camp to administer to this camper the over-the-counter medications indicated below.
The following over-the-counter medications will be on hand. Please check the ones you permit to be administered to your child.*

Hand SanitizerAcetaminophen (e.g. Tylenol)IbuprofenNone of the Above
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

Authorization for Camper to Self-Medicate, Monitor or Inject

For use of an EpiPen, inhaler or blood sugar monitoring devices (including insulin).
Camper Name*

First NameLast Name
Has this camper been prescribed/do they utilize (a) an EpiPen (b) an Inhaler OR (c) a blood sugar monitoring device due to diabetes?*

YesNo
If you answered "No" to the question above, please move on to the next section.
Regulations allow for capable campers to self-medicate under the following guidelines.
- If a child is capable of self-medicating using a prescribed EpiPen or inhaler, and the parent/guardian and the camp health care consultant give written approval, the camper may be allowed to carry these devices with him/her at all times in order to self- administer when necessary.
- If a diabetic child requires his/her blood sugar be monitored, or requires insulin injections, and the parent/guardian and the camp health care consultant give written approval, the camper who is capable may be allowed to self-monitor and/or inject him/herself. Blood monitoring activities and self-injection must take place in the presence of the health supervisor.
Please check to confirm below*

I herby state that my child is capable and reliable to self-medicate, monitor or inject and does have my permission to do so in accordance with the stipulations stated above.
Is there any other information that would be helpful for the camp staff to know regarding this camper and their use of one of these devices?
Parent/Guardian Name*

First NameLast Name
Signature of Parent/Guardian*

Clear
Date*

MonthDayYear
Date

Authorization to Administer Personal Medication

Camper supplied medication given during camp hours.
Camper Name*

First NameLast Name
This camper has personal medication that they will need to take during camp hours.*

YesNo
If you answered "No" to the question above, please move on to the next section.
Please check this authorization and complete the appropriate information below if you are authorizing the camp health supervisor to administer medication to a camper.*

I hereby authorize La Vida Adventure Camp to administer to this child the medication(s) indicated below, in accordance with Massachusetts regulations.
Name of Medication*
Diagnosis (at parent/guardian's discretion)
Dose given at camp*
Route of administration*
Frequency (Time(s) of day to be administered)*
Specific Directions (e.g. on empty stomach/with water)
Possible Side effects/adverse reactions
Further comments or other medications (at parent/guardian's discretion)
Parent/Guardian Name*

First NameLast Name
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date

La Vida Adventure Camp Physician's Form

Before attending camp, all campers must submit a copy of their most recent immunization record as well as a physical completed by a licensed healthcare provider within 18 months of their camp session.
Please attach below EITHER

1) A copy of the camper's most recent immunization record and a signed physical from the past 18 months.

OR

2) The La Vida Adventure Camp Physician's Form, including the camper's recent immunizations.
Please attach the forms here:

*If you are unable to upload the required forms to this window, you will need to submit them separately prior to your camper attending camp. These forms are due 2 weeks before your camp week.*
Cancelof

La Vida Adventure Camp Authorization for Camper Pickup
Camper Name*

First NameLast Name
Please list the names of any parent/guardian (including yourself!), carpool driver or family friend that is authorized to pickup your camper at Ferrin Field (also called Gavin Intramural Field) parking lot. If your child is planning on riding a bike to or from camp, please list that as well.*
Parent/Guardian Name*

First NameLast Name
Signature of Parent / Guardian*

Clear
Date*

MonthDayYear
Date
Once you have completed this form, please click Submit Form below. If you have more than one camper, you will need to complete a separate Camper Registration Form for each additional camper.
Should be Empty:

	NO	YES	DATE	EXPLAIN ANY DETAILS OF YOUR HEALTH CONDITION
Dizziness, Loss of Consciousness, Fainting
Asthma or Respiratory Disease
Allergies or sensitivity to Insect Bites
Carries an EpiPen
Major impairment of Sight or Hearing
Major Injury to Back, Joints, Bones
Artificial Limbs
Hemophilia or Bleeding
Pregnancy
History of Epilepsy or Stroke
Diabetes
Heart Disease or Pacemaker
Recent Surgery
Other

Camper Registration Form Packet

RELEASE AND ASSUMPTION OF RISK

LA VIDA ADVENTURE CAMP MEDICAL HISTORY AND EMERGENCY FORM

IN CASE OF EMERGENCY

Insurance

Physical Condition

La Vida Adventure Camp Medication Authorization Form

Massachusetts Regulations Regarding Camper Medication

Authorization to Administer Over the Counter Medication

Authorization for Camper to Self-Medicate, Monitor or Inject

Authorization to Administer Personal Medication

La Vida Adventure Camp Physician's Form

La Vida Adventure Camp Authorization for Camper Pickup