For “Sports Camps” students: Please download and submit the Summer Camp Health Record form
State regulations require we have parental contact information
and at least one emergency contact person.
Child’s Name (required):
Camps Child is Enrolled In (required):
Date of Birth (required):
Grade as of September 2016:
Parent/Guardian Name (required):
Relationship to Child (required):
Secondary Phone (required):
Second Parent/Guardian Name (required):
Additional contact person in the event parent/guardian cannot be reached (required):
Are there any legal restrictions on the release of your child or his/her records to a non–custodial parent (required)?
Please indicate if your child has had any of the following (required):
AsthmaBlood/Clotting DisordersDiabetesEpilepsyHeart Defects/DiseaseSeizuresOtherNone
My Child is allergic to (required):
DairyPeanutsSoyEggsSesameInsect StingFin FishShellfishTree NutsNo known allergies
Other allergy not listed above:
Does your child carry an EpiPen (required)?
If your child has a disability and requires accommodations in order to participate fully in program activities, please contact the Division of Lifelong Learning at 978-630-9525 to discuss specific needs.
What have we forgotten to ask? Please provide in the space below any additional information about your child that you think is important or may affect your child’s ability to fully participate in the MWCC Adventure Academy.
I hereby allow MWCC to photograph the child listed above for use in any type of media MWCC deems appropriate. This can include but is not limited to newspaper stories, printed literature and online information. I hereby give MWCC, its legal representatives and assigns, those for whom MWCC is acting, and those acting with its permissions, or its employees, the right and permission to copyright and/or use, reuse and/or publish, and republish photographic pictures.
I hereby allow MWCC to photograph the child listed above (required): YesNo
I give my permission for the child listed above to participate in Computer Use.
I agree to the computer use terms (required): YesNo
PERMISSION AND ASSUMPTION OF RISK AND RELEASE:
I give my permission for the child listed above to participate in the selected program(s). I understand that in the unlikely event of an accident, every attempt will be made to contact the person(s) named below. If unsuccessful, I give my permission to the staff to secure emergency medical services to aid my child, including (if necessary) hospitalization. Any expense arising from the injury or illness is the responsibility of the person signing below. In consideration of being permitted to participate in this program, I, the undersigned, in full recognition and appreciation of the dangers and hazards inherent in such activities, which are described in this brochure, during my child’s enrollment and/or participation in MWCC activities during this program, do hereby agree to assume all risks and responsibilities surrounding my participation in this program, or activities undertaken as an adjunct thereto; and I assume all risks for injuries and illness: caused by or related to this program: and further I do for myself, my heirs and personal representatives hereby defend hold, harmless, indemnify, and release, and forever discharge MWCC and all its officers, agents, and employees from and against all claims, demands, and actions, or causes of actions, on account of damage to personal property, or personal injury or death which may result from my participation, and which results from the causes beyond the control of, and without the fault or negligence of MWCC, its officers, agents or employees, during the period of participation.
I give my permission for the child listed above to participate in the selected program(s) (required): YesNo
Parent/guardian initials (required)
REGISTRATION IS NOT COMPLETE AND YOUR CHILD(REN) CANNOT ATTEND UNTIL THE MEDICAL/PERMISSION FORM IS SUBMITTED.