Youth Camper Registration and Release Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 4Registration Form Directions Please complete and submit the following demographic, medical history and emergency contact information for each of your child(ren) that are attending camp. For example, if you have two children that are attending camp, you will complete and submit two individual forms. Demographic InformationChild's First Name, Middle Initial, and Last Name *FirstMiddleLastChild's Birthdate (MM/DD/YY)Child's Grade (current grade if during the school year or rising grade if during the summer): *Pre-KKindergarden1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeChild's Gender *MaleFemaleOtherChilds Age (age they will be on the first day of camp): *Child's Race/Ethnicity (collected for grant funding purposes): *WhiteAsianHispanic or LatinoNative Hawaiian or Pacific IslanderBlack or African AmericanNative American or Alaska NativeTwo or more racesPrefer not to answerChild's Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMother/Guardian Name: *FirstLastMother/Guardian Mailing Address (List "same as child" if applicable): *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMother/Guardian Phone Numbers (home, work, and cell): *Mother/Guardian Place of Work: *Mother/Guardian Email Address: *Father/Guardian Name:FirstLastFather/Guardian Mailing Address (list "same as child" if applicable):Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeFather/Guardian Phone Numbers (home, work, and cell):Father/Guardian Place of Work:Father/Guardian Email Address:NextMedical/Developmental HistoryDoes your child have any known allergies? *YesNoIf your child has allergies, please list them here. If not, write N/A: *Does your child have any additional medical or developmental challenges or special needs? *YesNoIf your child has any additional needs, please list them here. If not, write N/A: *NextEmergency Contact InformationHospital preference in the event of an emergency: *Child's Doctor Name and Phone Number: *Child's Dentist Name and Phone Number: *In the event of an emergency, if parents/guardians cannot be reached, the people here may be contacted. At least TWO people must be listed here. *• Contact #1 Name/Relationship to Child and Phone Numbers (home/work/cell): • Contact #2 Name/Relationship to Child and Phone Numbers (home/work/cell): In addition to the parents/guardians and people listed above, the following people are authorized to pick up my child: *• Contact #3 Name/Relationship to Child and Phone Numbers (home/work/cell): • Contact #4 Name/Relationship to Child and Phone Numbers (home/work/cell): NextCamper Release/Waiver FormRelease and Waiver Form Directions Please read through each release/waiver/agreement in its entirety and provide your consent as requested for your child. A space is provided in each section for your initials, and a final signature is required at the bottom. We must have this form on file in order for your child to attend camp at Huntsville Botanical Garden. Authorization for Medical Release I hereby give permission to the Huntsville Botanical Garden staff to secure emergency medical, dental and/or surgical treatment for my child while in their care. All expenses of such care will be accepted by the parent(s)/legal guardian, including fees for an ambulance, if deemed necessary by staff. I realize attempts to reach me prior to any decisions will be made unless a life-threatening situation is at hand or circumstances do not allow. Medical Release – Parent/Guardian Initials: * Clear Signature Medical Release – Parent/Guardian Initials: Clear Signature Media Release During the course of the camp, Huntsville Botanical Garden may wish to use photographs of camp participants on bulletin boards, in educational publications or in general media releases on a controlled basis. Any such photographs would highlight the participant(s) either demonstrating learning techniques or participating in approved camp/garden activities. In accordance with Huntsville Botanical Garden policy, names of individual camp participants will not be released with any photographs. Child's Name *FirstLast people listed least Media Release Consent *I/We consent to the use of my child’s image; such use may include all Huntsville Botanical Garden Publications (print, online, video, etc.). Such photographs would highlight the camp participants either demonstrating learning techniques or participating in approved camp/garden activities.I/We DO NOT consent to the use of my child’s image ever, this includes all Huntsville Botanical Garden Publications (print, online, video, etc.)Media Release – Parent/Guardian Initials: * Clear Signature Media Release – Parent/Guardian Initials: Clear Signature Liability Release In consideration for the cultural and educational benefits which my child, *enter name below*, will receive by attending Camp, I hereby release the Huntsville Botanical Garden, all their directors, employees, volunteers, and any person associated with the Huntsville Botanical Garden, from any liability for any bodily injury and property damage suffered by my child as a result of activities during the educational program. Child Name *FirstLastLiability Release – Parent/Guardian Initials: * Clear Signature Liability Release – Parent/Guardian Initials: Clear Signature Camper Behavioral Expectations and Agreement Staff to Student Ratio Notice- HBG guarantees a Staff to Student Ratio of 1/10 (1 instructor to 10 students) throughout the camp day. At the Huntsville Botanical Garden (HBG), we take the happiness and safety of our campers seriously. Therefore, we work very hard to create a safe and fun environment. Along with our efforts, we need the children to help us by following some simple rules. Please read the Camper Behavior Expectations with your child and ensure they understand our camp’s behavior policies. I will listen to the Instructor(s) and follow directions. I will respect other camper’s belongings by not touching their things without permission. I will respect all property and help clean personal messes leaving areas clean. I will respect other camper’s personal space by keeping my hands and feet to myself. I will act in a caring way, and I will not hit, fight, bite, tease, harass or bully others. I will use appropriate language, which does not include swear words or insults. Not abiding by these rules may result in suspension or removal from the program. All incidents will be handled on a three incident system, except hitting, fighting, and inappropriately touching another camper. Hitting, fighting, and inappropriately touching another camper will be an immediate one-day suspension from the program. All other incidents will be handled as follows: First incident = Verbal warning Second incident = Written note to Guardian; reflection time* during free time (5 minutes) Third incident = Contact Guardian; reflection time* during free time (10 minutes) More than three incidents may subject the camper to dismissal from the program. *Reflection time includes sitting out with an Instructor(s) to talk about their behavior and how we can help the camper work through the problem resulting in better choices moving forward. Huntsville Botanical Garden management reserves the right to dismiss a child from the camp if the child’s behavior is disruptive to the program and/or compromises the happiness and safety of themselves, other children, and/or staff. Children suspended or terminated from the program will not qualify for a refund. Behavioral – Parent/Guardian Initials: * Clear Signature Behavioral – Parent/Guardian Initials: Clear Signature Release Signature By signing, I agree to partner with Huntsville Botanical Garden in making my child’s camp experience positive for all children and families involved. Release – Parent/Guardian Signature: * Clear Signature Typed Name: *FirstLastDate:Submit