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Registration – DRIVE 23 – Camper
Ali A.
2023-02-27T22:46:37-05:00
Participant(s) Information
Number of participants you are registering?
(Required)
1
2
3
4
5
Participant Full Name
(Required)
First
Last
Participant Gender
(Required)
Male
Female
Participant Date of Birth
(Required)
MM slash DD slash YYYY
Participant Phone Number
(Required)
2nd Participant Full Name
(Required)
First
Last
2nd Participant Gender
(Required)
Male
Female
2nd Participant Date of Birth
(Required)
MM slash DD slash YYYY
2nd Participant Phone Number
(Required)
3rd Participant Full Name
(Required)
First
Last
3rd Participant Gender
(Required)
Male
Female
3rd Participant Date of Birth
(Required)
MM slash DD slash YYYY
3rd Participant Phone Number
(Required)
4th Participant Full Name
(Required)
First
Last
4th Participant Gender
(Required)
Male
Female
4th Participant Date of Birth
(Required)
MM slash DD slash YYYY
4th Participant Phone Number
(Required)
5th Participant Full Name
(Required)
First
Last
5th Participant Gender
(Required)
Male
Female
5th Participant Date of Birth
(Required)
MM slash DD slash YYYY
5th Participant Phone Number
(Required)
MEDICAL FORM
Past medical history
(Required)
EX: asthma, seasonal allergies, tonsillitis, strep throat, croup
Please list any recent hospitalizations if any:
(Required)
EX: appendectomy 2012
Current medications
(Required)
EX: Albuterol; 90mcg; 1-2 puffs every 6 hours as needed
Campers are responsible to bring medication with them
Name
Dose
Frequency
Add
Remove
Food and drugs allergies
(Required)
Name
Reaction
Add
Remove
Other Issues
(Required)
Please check any medications the registered nurse can administer to your child while at camp if needed:
Tylenol
Benadryl
Motrin
Antibiotic Ointment
Hydrocortisone Cream
Stool Softener
Please provide a headshot for the participant(s)
(Required)
Drop files here or
Select files
Max. file size: 80 MB.
Please provide a copy of the insurance card(s) attached to this form in case of an emergency
(Required)
Drop files here or
Select files
Max. file size: 80 MB.
Retreat Information
In this section, the parent/ the participant need to agree to the retreat waiver, medical Form and the cellphone rule.
Retreat Waiver
I agree to the retreat waiver.
I, the undersigned attendee the (“Participant”) do hereby consent to participating in the D.R.I.V.E. Retreat (“DRIVE”), a project of The Mainstay Foundation (“Mainstay”).
I acknowledge that my participation in DRIVE may expose me to a variety of risks, including but not limited to, the possibility of injury or death. I grant the DRIVE Staff authority to obtain emergency medical treatment for me when deemed necessary. I agree to waive and release Mainstay, its employees and agents, from all claims, causes of action, grievances, and liabilities, both in law and equity, for damages that may arise as a result of my participation in DRIVE.
I acknowledge that I will travel by automobile or bus to the campsite. I agree to waive and release Mainstay, its employees and agents, from all claims, causes of action, grievances, and liabilities, both in law and equity, for damages that may arise as a result of my commute to and from the campsite.
I acknowledge that many pictures and/or videos will be taken throughout DRIVE and used for marketing and promotional purposes. I consent to being in the photographs and/or videos. My name/identification may be published.
Finally, I acknowledge that if I desires to leave the campsite for any reason before the scheduled departure, I will be responsible for arranging transportation and covering any associated costs.
I acknowledge and confirm that I have read this entire document prior to signing below.
Cell Phone Rule
I agree to the cellphone rule.
I/We, the participant(s), agree to the following:
• I promise I will take a break from my phone during this retreat and enjoy the beautiful scenery and fun activities.
• I promise I will not waste my time on my phone and remain active and healthy during the retreat.
• I promise I will not use my phone at the lake.
• I promise I will not take any pictures, video, etc. of any of the female participants who observe the Hijab without their headscarves on.
• I promise I will not take any pictures, video, etc. of any participant without their explicit consent.
• I promise I will not post any pictures, video, etc. on any social media outlet (Facebook, Instagram, Snapchat, etc.) without the explicit consent of everyone in the picture, video, etc.
I understand that violation of any of these rules will result in immediate expulsion from the camp.
I have read the above statements and agree to abide by these rules while participating at the DRIVE Retreat.
Parent/Guardian Information & Payment
This information will be used to contact in case of an emergency.
Name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
Prefix
First
Last
Phone Number
(Required)
Email Address
(Required)
Registration Fee
(Required)
Price:
$0.00
Cost per participant is $300.00
Coupon
Total
Credit Card
(Required)
Card Details
Cardholder Name
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