Healing to Fly - Participant Registration

The following is for the Healing to Fly weekend at Camp Hope for Kids on May 16 - May 18, 2025.

The following must be completed by the parent/guardian of the participant.

Participant Information

Camper first name

Camper last name

Camper Phone

Gender

Male

Female

Camper Date of Birth

Month

Day

Year

Current Grade

Name of School Currently Attending

Parent Guardian Information

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Participant Medical Information

Emergency Contact Name

Relationship Participant

Emergency Contact Phone Number

Allergies

List all known allergies and describe how each reaction is managed.

If no known allergies, please write NONE.

Medication Allergies:

Food Allergies or Restrictions:

Other allergies:

Health Conditions

Does your child have any current or recent physical health conditions?

Does your child have any current or recent mental health conditions?

Does your child have any activity restrictions?

Medications Taken

Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Be sure that the attendee brings enough medication to last the entire time at camp in the original package/bottle that identifies the prescribing physician, name of the drug, dosage, and frequency.

This will be given to the first aid station upon arrival.

Medication #1, dosage, frequency

Medication #2, dosage, frequency

Medication #3, dosage, frequency

Medication #4, dosage, frequency

Permission to Administer Over the Counter Medication

Please indicate your permission to administer over-the-counter medications while the applicant is at camp.

Ibuprofen (Advil/Motrin)

Yes

Acetaminophen (Tylenol)

Yes

Benadryl

Yes

Sudafed

Yes

Imodium (anti-diarrheal)

Yes

Tums

Yes

Benzocane (Orajel/Anbesol)

Yes

Cough Drops

Yes

Dramamine

Yes

Guaifenesin (for cough) i.e. Robitussin

Yes

Peroxide

Yes

Antibiotic Ointment

Yes

Bismuth Subsalicylate (Pepto Bismol)

Yes

Loratadine (Claritin)

Yes

Cetirizine (Zyrtec)

Yes

I, the parent or guardian of the above named attendee, request that the personnel at Camp Hope for Kids administer medication to my child in accordance with the medication instructions.

Yes

Other

Date of Last Tetanus Immunization

Month

Day

Year

Waiver and Release of Liability

This Release and Waiver of Liability (the “Release”) executed on this (date entered below) day of (month entered below), (year entered below), by (Volunteer/Attendee Name entered below) in favor of Hope for Kids, LLC. (“Hope for Kids”) a nonprofit organization, and each of their directors, officers, employees, and agents, TSF, in addition to Beckett Life Center, Union Housing Development Corporation, Beckett Gardens 11, One Day at a Time, Black Brain Campaign, NWON, and its component organizations, and all claims for injury, illness, death, loss or damage as a result of any Hope for Kids program activity. The volunteer/attendee desires to work for Hope for Kids and engage in activities related to being a volunteer. I, the volunteer/attendee, hereby freely and voluntarily, without duress, execute this Release under the following terms:

This Release and Waiver of Liability (the "Release") is in favor of Hope for Kids, Inc., a nonprofit organization, and The Solomon Foundation and each of their directors, officers, employees, and agents, in addition to Beckett Life Center, Union Housing Development Corporation, Beckett Gardens 11, One Day at a Time, Black Brain Campaign, and NWON, I, hereby freely and voluntarily, without duress, execute this Release under the following terms:

In consideration of the risk of injury while participating as a camper at the property owned by The Solomon Foundation and leased by Hope for Kids, Inc. (including but not limited to: swimming, sports, boating, hiking, rock wall climbing and zip-lining), and as consideration for the right to participate in these Activities, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation as a volunteer at the Forge , and do hereby release and forever discharge Hope for Kids, Inc. & The Solomon Foundation , located at 129 Yerger Rd, Schwenksville, Pennsylvania 19473, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, exposure to infectious/communicable disease, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activities, including traveling to and from an event related to this Activities.

I acknowledge that participation in the activities described above involve risk to the camper (and to the camper's parents or guardians, if the camper is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the camper (or parent/guardian if the camper is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The camper (or parent/guardian) accepts personal financial responsibility for any injury or loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the camper that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the camper (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the camper or otherwise.

If a dispute over this agreement or any claim for damages arises, the camper (or parent or guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the camper (or parent or guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

By checking the boxes below, I am indicating my agreement to the following statements:

I understand the Director reserves the right to dismiss any camper whose behavior/attitude is detrimental to the welfare of the camp or whose conduct is not in accord with the standards of Hope for Kids, Inc.

I understand that in the event of dismissal or withdrawal on account of homesickness, misconduct or any other cause except for medical emergencies, that no refund will be given. I understand that I will be responsible for picking up my child in the event of dismissal or withdrawal. No special bus transportation or other transportation will be arranged on behalf of my child in this event.

I authorize the use of the camper's photo in any camp promotions (website, brochure, etc.).

Should it be necessary for the above-named camper to receive emergency medical attention or treatment while participating in a week of camp , I hereby give permission for the person(s) leading or directing the camp activities (the Camp Directors), to administer emergency medical treatment (i.e., first aid, CPR, etc.) to the participant or secure the services of an ambulance, hospital, physician or other medical professional to treat the participant as the Camp Directors deem necessary.

I understand that Hope for Kids, LLC, The Solomon Foundation, in addition to Beckett Life Center, Union Housing Development Corporation, Beckett Gardens 11, One Day at a Time, Black Brain Campaign, NWON, and Camp Directors have no health insurance to cover medical or hospital costs incurred by the participant; therefore, financial responsibility for any medical or hospital costs shall be the sole responsibility of the Parent/ Legal Guardian.

I understand that none of the Camp Directors or Volunteers leading or directing these activities may accept responsibility for alerting a camper about required medication or administering such medication.

I understand that arriving to camp healthy is vital to a healthy camp experience for all. On behalf of myself and my family, I agree to follow all Covid-19 safety guidelines initiated by Hope for Kids in accordance with the regulations of the Commonwealth of Pennsylvania. I understand that if I/we show symptoms of Covid-19 the camper will not be able to remain on camp unless approved by the medical director.

As evidenced by my typed name below, I expressly agree that this Release is intended to be as broad and inclusive as permitted by laws of the State of Pennsylvania in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. I agree that if in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable.

I affirm that I am the PARENT/GUARDIAN for the Applicant and am 18 years or older, and that I am freely signing this agreement. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am agreeing to it of my own free will.

Signature

Signature field is empty.

LAST STEP!

Please click on this link and complete the waiver. After completing the waiver, come back to this form and submit.

https://www.jotform.com/sign/251285311533046/invite/01jtx8ye2jb3ef0456a7e4029f

Did you complete the form using the link above?

Yes

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