CAMP SIGN-UP Spring Break & Summer 2020 RM_StatsIf this is your first time signing up with Move Build Play, please create an account below. If you are already logged in, you will see your email inputted and you can continue to fill in the Registration Form. Please make sure you read all the Event Information prior to registering your child.Email *Password *Password must be at least 7 characters long.Enter password again *Password must be at least 7 characters long. Family InformationFamily Last Name *Home Address Address Line 1 Address Line 2 City State or Region AL AK AZ AR AA AE AP CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State or Region Country Zip Emergency ContactFirst Name *Last Name *Relationship *Phone Number * Authorized Pick Ups & Contact NumberParent/Guardian #1Parent/Guardian First Name *Parent/Guardian Last Name *Relationship *Primary Number *MobileEmail * Parent/Guardian #22nd Parent/Guardian First Name2nd Parent/Guardian Last NameRelationshipPrimary NumberMobileEmail Child's InformationParticipant #1Camper’s Last Name *Camper’s First Name *DOB *School *Special Needs/Disabilities/Sensitivities (i.e., sensory issues, excessive screen time, interests, etc) *Allergies and Medications *Primary Care Physician and Contact Number *T-shirt Size *Select an optionSmallMediumLargeX-LargeWould You Like to Register Another Child? *Select an optionYesNo 2nd Camper’s Last Name2nd Camper’s First Name *DOBSchoolSpecial Needs/Disabilities/Sensitivities (i.e., sensory issues, excessive screen time, interests, etc)Allergies and MedicationsPrimary Care Physician and Contact NumberT-shirt SizeSelect an optionSmallMediumLargeX-LargeWould You Like to Register Another Child? *Select an optionYesNo3rd Camper’s Last Name *3rd Camper’s First NameDOB *School *Special Needs/Disabilities/Sensitivities (i.e., sensory issues, excessive screen time, interests, etc) *Allergies and Medications *Primary Care Physician and Contact Number *T-shirt Size *Select an optionSmallMediumLargeX-LargeWould You Like to Register Another Child? *Select an optionYesNo4th Camper’s Last Name *4th Camper’s First Name *DOB *School *Special Needs/Disabilities/Sensitivities (i.e., sensory issues, excessive screen time, interests, etc) *Allergies and Medications *Primary Care Physician and Contact Number *T-shirt Size *Select an optionSmallMediumLargeX-Large Our PoliciesParticipant Expectations *Yes, my child/ren is mentally and physically ready for an unstructured play settingAll Participants must come mentally and physically prepared to follow basic instructions and rules for the safety of all Campers and Move Build Play staff. With this being said, Move Build Play LLC reserves the right at their discretion to dismiss a camper if their behavior is inappropriate or jeopardizes the other campers’ safety and well-being. Inappropriate language, bullying or bringing harm to a fellow Camper or staff will not be tolerated at Move Build Play.Release of Liability *I have read and agree to the Release of LiabilityINFORMED CONSENT, RELEASE AGREEMENT, AND AUTHORIZATION I understand that participation in Move Build Play, and its activities involves the risk of personal injury, including death, due to the physical, mental, and emotional challenges in the activities offered. Information about those activities may be obtained from Move Build Play, its Directors and activity coordinators. I also understand that participation in these activities is entirely voluntary and requires participants to follow basic instructions and abide by all applicable rules and the standards of conduct. In case of an emergency involving my child, I understand that efforts will be made to contact me. In the event I cannot be reached, permission is hereby given to the medical provider to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child. Medical providers are authorized to disclose protected health information to the adult in charge and/or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant's parents or guardian, and/or determination of the participant's ability to continue in Move Build Play’s activities. I understand that the cost of all emergency medical services is my responsibility. I understand that my Child’s participation at Move Build Play exposes them to certain risks of being in the outdoors. Accidents and injuries resulting from the forces of Mother Nature, live animal and bug interactions, slipping and falling, malfunctioning equipment, unseen obstacles, fatigue, and your own or other’s misjudgment are very real possibilities. With appreciation of the dangers and risks associated with Move Build Play and its activities, its venues (Village of Palmetto Bay and the Girl Scouts of Tropical Florida), I hereby fully and completely release and waive any and all claims for personal injury, death, or loss that may arise against the Move Build Play LLC, it’s Directors, activity coordinators, and all employees, volunteers, related parties, or other organizations associated with any program or activity.Media Release *I have read and agree to the Media ReleaseI hereby assign and grant Move Build Play the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of the Participants by Move Build Play LLC, and I hereby release Move Build Play LLC from any and all liability from such use and publication. I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of Move Build Play LLC and I specifically waive any right to any compensation I may have for any of the foregoing.Cancellation & Payment Policies *I have read and agree to the Cancellation and Payment PoliciesI have thoroughly read, understand, and agree with the policies and procedures in reference to the cancellation and payment policies of Move Build Play LLC. I will be charged the full tuition amount for my event upon checkout. ALL CANCELLATIONS/NO-SHOWS ARE INELIGIBLE FOR A REFUND. There will be no refunds for cancellations due to acts of God (including weather related cancellations), natural disasters, or epidemics. We recognize that such events are unlikely to occur; but if one does, we will issue credit vouchers for the full amount paid for the affected program.Payment - Please Select the Correct Amount (Up to 4 Campers) * Fireflies & Forts ($ 210) × Rockets & Rotors ($ 210) × M.U.D.Stravaganza ($ 210) × Shop Class ($ 210) × I AGREE TO ALL OF THE ABOVE *Additional InformationPlease take a few seconds to review and confirm that all of the information above is correct before submitting. Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
