Blue Hawk Summer Camp Medical Information & Liability Waiver Form
Please complete this form 2 weeks before your camp date to allow your student to participate in the activities during their upcoming Blue Hawk Summer Camp program.
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Email *
Name of Student *
Nickname / preferred name
Primary contact phone number *
Address *
Date of program. If your student is planning to attend multiple dates, please select all that apply. *
Required
Name & phone number of an emergency contact. Please include their relationship to the student (e.g. parent, grandparent, guardian, family friend). *
Allergies: Does this student have any allergies (e.g. bees, drugs, foods, etc.)? If yes, to what and what is the severity of the reaction? *
Medications: Is your student currently taking medications? If yes, what are they taking and what condition is being treated? *
Chronic Illness: Does your student have any chronic illnesses (e.g., diabetes, epilepsy, asthma, etc.)? If yes, please list. *
Physical Conditions: Does your student have any physical conditions that might limit or affect their ability to participate in physical activities? If yes, please describe such limitations and conditions for participation. *
Social, Emotional, or Developmental Considerations (e.g. ADHD, Asperger's, an anxiety disorder, etc.)? Has this student been diagnosed with any social, emotional, or developmental needs? If yes, please explain so we may be as inclusive and sensitive as possible.  *
Injuries: Has this student experienced any injuries (e.g., dislocations, sprains, etc.) within the last three years? If yes, please identify the injuries, when they occurred and the severity of the injuries. Has this student fully recovered from the injury? *
Accommodations: Are there any accommodations we can make for the aforementioned illnesses, conditions, considerations or injuries? *
Physician: Has the student been treated by a physician in the past year? Have they been hospitalized within the past year? If yes to either, please explain. *
Primary Physician: Name & phone number *
Insurance Provider: carrier name & I.D. number (if # available) *
Release of Liability Section
The Blue Hawk Summer Camp program will provide activities that offer participants an opportunity to explore new behaviors related to trust, teamwork, and leadership capabilities. These activities include field games, indoor games and problem solving activities. The Exeter Regional Cooperative School District (ERCSD)have taken precautions to provide proper equipment, qualified instructors, and a carefully designed program. Students will receive instructions related to all program activities. 

Adventure activities (indoor and outdoor) are exciting, challenging and both physically and emotionally demanding. Some activities may be stressful and have inherent risk. Even with qualified staff and proper preparation, it is impossible to guarantee absolute safety. While it is the aim and the responsibility of ERCSD to provide students with a positive and safe experience, you must realize that there is a degree of risk and personal responsibility for safety when you participate in adventure activities. 

Our philosophy is Challenge by Choice, meaning that students agree to choose their own level of challenge and agree not to be coerced by others in going beyond their physical limitations. Furthermore, while some activities are physically demanding, our program is designed and can be adjusted to be within the capability of anyone who is in reasonably good health. 

By consenting to participation, you assume all risks related to adventure activities, including the possibility of bruises, abrasions, sprains and other more serious injuries. Agreeing to this form indicates your recognition and understanding of the responsibilities and risks inherent in your participation. In the event of illness or injury, consent is hereby given to provide emergency medical care or hospitalization. 
Please confirm with your digital signature below that you have read this information and that you:
1 - Understand your child’s responsibility as a participant, that extent of participation is voluntary and that your child is free to discontinue or modify participation at any time before or during the activity;

2 - Have disclosed medical or other restrictions that would affect your child’s participation;

3 - Acknowledge that Exeter Regional Cooperative School District (ERCSD) does not maintain insurance against accidental injury for the benefit of the student and certify that the student’s medical expenses are covered by a medical insurance policy, or if not, accept absolute financial responsibility for such in the event that such expenses are incurred;

4 - Release and covenant not to sue ERCSD, and all ERCSD’s officers, agents, and employees, for a claim, of any kind, in any way related to or as a result of the student’s participation in the activity, whether the injury results from the alleged negligence or other tortious act of ERCSD or any ERCSD officers, agents, or employees, excepting only injuries suffered as a result of an act of an ERCSD employee which was intended to cause injury to the student; and agree to indemnify ERCSD and ERCSD officers, agents, and employees against and hold ERCSD and all ERCSD officers, agents and employees harmless from any and all claims of any kind made by the student or any other person in any way arising out of the student’s participation in the activity whether resulting from the alleged negligence or other tortious act of ERCSD and or ERCSD officers, agents or employees excepting only injuries suffered as a result of any act of an ERCSD employee which was intended to cause injury to the Student or the other injury which is the basis of the claim.

5 - Know that there are risks involved in a summer camp program and assume all of the risks of participating in the summer camp program.
Please indicate your approval for your student's participation with the Blue Hawk Summer Camp: *
Parent / Guardian name *
Photo Permission: I hereby grant Exeter Regional Cooperative School District (ERCSD) permission to use my student's photographic likeness, videotape, or digitally record their participation in the program activities in their promotional, informational, and educational materials. *
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