Parent or Guardian Name
Second Parent or Guardian Name
Physician & Insurance Information
Please list up to three additional contacts that should be reached in case parents or guardians cannot be reached in the event of an emergency
Participant's General Health History
Please list any medical conditions your child has in order to allow our teachers to provide the safest and best possible experience for them
i.e. food, medicine, seasonal, environmental, etc.
Has this child ever had or been treated for any of the following ? (Please check all that apply)
Please list all medications and the dosage your child is currently administered regardless of their need to take them during our program. In the event of an emergency, we would share this list with medical care providers.
If your child needs to take any medication or carry an epi-pen and/or inhaler, you must complete an Authorization to Administer Medication form. This is available in the confirmation email you received after registering and on the summer watershed discovery page of westportwatershed.org. This must be received at least one week before your child's session begins. All medications must have the pharmacy label on them.
*** Please be aware that WRWA staff will be checking I.D.s to ensure your child's safety. WRWA will not allow your child to go home with anyone who is not listed as a parent or guardian, who is not listed below, or who is unable to show proof of identity. Please inform people on your list that they must have a license to show our staff. ***
Please Even though WRWA is not a swimming focused program, we want to understand your child's swimming ability and your comfort with them doing activities at the water's edge or in shallow depths below knee level.
Sunscreen/Insect Repellant Release
I understand that outdoor exploration is an integral part of WRWA’s Watershed Discovery Programs and that my child will be exposed to risks, including but not limited to, sun, ticks, poison ivy, and insects. I understand that it is my responsibility to apply sunscreen and insect repellant to my child before bringing them to camp each day. I also understand that I am responsible for supplying sunscreen and insect repellant, labeled with my child’s name, so that it can be reapplied by my child or WRWA staff during the day, and that due to possible skin reactions WRWA is not able to provide these for children or allow children to share their supply with others. I understand that some ticks may transmit disease after being attached for over 24 hours, and it is my responsibility to check my child’s body thoroughly every day and to remove any ticks that may become attached. WRWA staff regularly check for ticks and will remove any that are not deeply embedded.
Permission to Participate and Medical Release
Medical Release: I certify that the health history provided above for my child is correct and that my child is healthy and free of problems that could be deleterious to their participation or that of other participants while in the Watershed Discovery Program
I hereby give permission to the WRWA staff to provide routine health care, administer prescribed or over-the-counter medications that I have provided as described, to arrange necessary related transportation for my child in the event of an emergency, and understand there may be charges for which I shall be held responsible.
I give permission to WRWA staff to provide or obtain emergency care. In the event I can not be reached, I give permission to the physician to secure proper treatment or hospitalization, order and administer medications and anesthesia, perform x-rays, special procedures, or surgery if deemed medically necessary by him/her for my child, for which charges I shall be held responsible. I understand this document will be provided to the appropriate physician, dentist, or medical representative in the event of an emergency.
Covid: I understand that WRWA will be mindful of distance when indoors, will have children wash or sanitize their hands regularly, and will not allow sharing of food or supplies that come in contact with a child’s face such as cameras, magnifying lenses, etc. If my child tests positive for Covid I understand they will need to quarantine for five days before being allowed into a summer program, and that I will not receive a refund for missed days.
Insurance: I certify that the named child is covered by health and accident insurance or Medicaid and that the policy information provided is correct.
Risk: I understand there are inherent risks in outdoor programs and that although WRWA takes every measure to ensure safety; it is not possible to foresee every contingency or to eliminate all risk. Program activities include hiking on uneven terrain, collecting animals, playing active games, participating in activities in and near the water and more. I agree on behalf of my child to assume such risks and understand that my child shares the responsibility for their own safety during WRWA programs and activities.
Release/Permission to Participate: I hereby release and forever discharge, agree not to sue, and agree to indemnify and hold harmless the Westport River Watershed Alliance, its agents, employees, interns, and organizational partners, including but not limited to, the Town of Westport, Westport Community Schools and the Westport Land Conservation Trust, from any and all liability, loss, damage, expense, causes of action, suits, claims or judgements for injury to the above-named minor or other persons or their property arising out of, or in connection with, my child’s participation in the Watershed Discovery Programs.
I grant permission for my child to participate in all program activities except those noted below:
I hereby give permission for photographs, images, or videos of my child, and his/her creative materials (poems, drawings, stories etc.) to be used for publicity, public relations, promotional materials and/or newsletters.
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