2018 APPLICATION / REQUIRED FORM

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1 2018 APPLICATION / REQUIRED FORM All questions must be answered. Please complete and return with all forms / Fax: / camps@babson.edu Summer Programs Office, Nichols Hall / Babson Park, MA OR REGISTER ONLINE AT: CAMPER FIRST NAME CAMPER LAST NAME OF BIRTH SCHOOL GRADE IN FALL 2018 GENDER: MALE/FEMALE MAILING ADDRESS CITY STATE ZIP CODE PARENT 1 NAME PARENT 1 PARENT 2 NAME PARENT 2 PARENT 1 PHONE 1 PARENT 2 PHONE 1 PARENT 1 PHONE 2 PARENT 2 PHONE 2 PARENT 1 PHONE 3 PARENT 2 PHONE 3 EMERGENCY CONTACT (OTHER THAN PARENT) PHONE 1 PHONE 2 DOES CAMPER HAVE PERMISSION TO PARTICIPATE IN THE OPTIONAL SWIM? YES NO DO YOU CARRY MEDICAL/HOSPITAL INSURANCE? YES NO IF YES, NAME OF CARRIER POLICY/GROUP NUMBER SUBSCRIBER NAME OF FAMILY PHYSICIAN PHYSICIAN ADDRESS CITY STATE ZIP CODE PHYSICIAN PHONE CAMPER MEDICAL INFORMATION DOES CAMPER HAVE: DIETARY RESTRICTIONS/FOOD ALLERGIES? YES NO NON-FOOD ALLERGIES? YES NO ANY MEDICATIONS CURRENTLY TAKEN? YES NO ANY NEUROLOGICAL CONDITIONS YES NO ANY MEDICATIONS THAT WILL BE TAKEN DURING CAMP HOURS? YES NO SIGNATURE OF PARENT/GUARDIAN Application will not be processed unless all above information is complete. Babson College prohibits discrimination on the basis of race, color, national or ethnic origin, ancestry, religion, sex, sexual orientation, age, physical or mental disability, and veteran or other protected status. This policy extends to all rights, privileges, programs, and activities, including admission, employment, education, and athletics.

2 2018 APPLICATION CONTINUED / REQUIRED FORM / Fax: / camps@babson.edu Summer Programs Office, Nichols Hall / Babson Park, MA Please select all sessions you wish to attend CAMPER S NAME OF BIRTH Please select programs and dates. Tuition BASEBALL Ages 6 12 q June $495/SESSION BOYS BASKETBALL Ages 6 14 q July 9 13 q July q July $495/SESSION BOYS LACROSSE Ages 8 14 q July q Junior Camp q Senior Camp q Goalie $495/SESSION BOYS SOCCER Ages 7 17 q July 9 13 q July q Junior Camp q Senior Camp q Goalie $495/SESSION FIELD HOCKEY Ages q June q Goalie $495/SESSION GIRLS LACROSSE Ages 8 17 q July 30 August 3 q Junior Camp q Senior Camp q Goalie $495/SESSION GIRLS SOCCER Ages 7 17 q July q Goalie $495/SESSION ICE HOCKEY Ages 6 13 q June q July 9 13 q Goalie $630/SESSION VOLLEYBALL Ages 7 17 q August 6 10 $495/SESSION TENNIS Ages 8 15 q June q June $495/SESSION MULTIPLE SESSIONS OF THE SAME CAMP ARE 10 PERCENT OFF EACH SESSION. Please remember to send in your camper s Physical and Immunization history (provided by your physician) with these forms. Babson College complies with the State of Massachusetts Camp Regulations (105 CMR 430) and is permitted by the Wellesley Health Department.

3 PAYMENT / REQUIRED FORM / Fax: / camps@babson.edu Summer Programs Office, Nichols Hall / Babson Park, MA DEPOSIT/TUITION POLICY A nonrefundable deposit of $100 per camp session must accompany this application. Example: A child going to one session of soccer camp, one session of basketball camp, and two sessions of ice hockey camp would submit a deposit of $400. Withdrawal or cancellation prior to the first day of camp for any reason will result in a full refund less the nonrefundable deposit of $100 per camp session. All withdrawals or cancellations must be made in writing and received prior to the first day of camp. Balance of tuition must be received by May 31, Applications received after May 31, 2018, must be paid in full. All fees may be paid by check (payable to Babson College), Visa, or MasterCard. A check is enclosed for $ Charge the amount of $ to my Visa MasterCard Amex Card number Last 3 digits on back of card Expiration date Cardholder s name Signature CELL PHONE POLICY Cell phones are prohibited during camp hours. PHYSICIAN FORM POLICY Physician forms from your doctor, including your child s record of immunizations, must be received by the camp office by May 31, Failure to turn in these forms will result in the loss of your son or daughter s admittance to the Babson camps. These forms are required by the Commonwealth of Massachusetts. MEDICAL EMERGENCY AGREEMENT In case of a medical emergency involving my child/ward, I understand that every effort will be made to contact me or other parent/guardian/alternate person. In the event I or they cannot be reached, I hereby give permission to the physician selected by the camp to hospitalize, to secure proper treatment for, and to order injection, anesthesia, surgery, or other medical procedures necessary for my child. I have read the above and understand the camp s policy concerning tuition and nonrefundable deposits. I understand that my child s reservation may be canceled by the camp if the balance of the tuition and the Physical and Immunization Form have not been received by May 31, Deposit enclosed $ Signature Date Application will not be processed without a signed Release of Liability form on the next page.

4 RELEASE OF LIABILITY / REQUIRED FORM / Fax: / camps@babson.edu / Summer Programs Office, Nichols Hall / Babson Park, MA RELEASE, HOLD HARMLESS, COVENANT NOT TO SUE, ASSUMPTION OF RISK AND INDEMNIFICATION I, (parent name), of (city, state), in consideration of my Child s participation in the Summer Camps at Babson College during the summer of 2018, do hereby agree as follows: Child s name: Please read carefully. This is a release and waiver of important legal rights. Although reasonable precautions are taken to provide proper organization, instruction, and equipment for your Child s participation in the Summer Camps at Babson College, there can be no guarantee of absolute safety against injury and accident. There are elements of risk in any sport or program involving physical exertion and risk taking (individually, an Activity and collectively, the Activities ) and the use of any equipment in connection with the Activities. I, on behalf of myself and my Child, understand that my Child may be involved in Activities, including but not limited to, arts and crafts, baseball, basketball, field hockey, ice hockey, lacrosse, soccer, swimming, team-building initiatives, tennis, games, volleyball, and/or other physical undertakings. I acknowledge that participation by my Child in any Activities is voluntary and that my Child may decline to participate in any Activities. ACKNOWLEDGMENT OF RISKS: I recognize that there is inherent danger in any Activities that involve physical exertion or risk taking; that although the program may not be strenuous, injuries or medical complications may occur; that certain foreseeable and unforeseeable events unique to each Activity can contribute to the unpredictability of the Activity; and that balance, physical coordination, and conditioning may affect the occurrence of accidents, falls, and injuries. EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY: In recognition of the inherent risks of the Activities in which my Child will be engaged, both seen and unforeseen, I confirm that my Child is capable of participating in the Activities and/ or using equipment in connection therewith. I assume full responsibility for personal injury, accidents or illnesses, including death to my Child, except to the extent caused by the negligence of Babson College or anyone for whom it is legally responsible. I also assume responsibility for loss of or damage to my Child s personal property. On behalf of myself and my Child, I assume the risk(s) of personal injury, accidents, and/or illnesses of all kinds and nature, including, but not limited to, cuts, wounds, scrapes, abrasions, and/or contusions, sprains, and/or death. AUTHORIZATION: I hereby authorize any medical treatment deemed necessary in the event of any injury to my Child while participating in the Activities. I have appropriate insurance or, in its absence, I agree to pay all costs of medical services and medical transport as may be incurred on behalf of my Child. RELEASE, HOLD HARMLESS AND COVENANT NOT TO SUE: In consideration of my Child s participation in the Activities, I do hereby for myself, my Child and our respective administrators, executors, heirs, spouse, dependants, successors, and assigns, knowingly and intentionally release, forever discharge and covenant not to sue Babson College and its trustees, officers, agents, employees and volunteers (collectively, College ) from and against any claims, demands, expenses, actions and causes of action of every name, type, and nature I or we now have or may ever have arising out of my Child s participation in the Activities on the above dates and on any subsequent dates during which he or she participates in the Activities. AUTHORIZATION: I hereby authorize and give the Summer Camps at Babson College permission to take, use, publish, and reproduce photographs, videos, and other images of my Child for the Summer Camps at Babson College records, website, brochures, group photos, or other media. ACKNOWLEDGMENT: In signing this Agreement, I acknowledge and represent that I have fully reviewed it and understand what it means, and that I sign this document as my free act and deed. No oral representations, statements, or inducements, apart from the foregoing written statement, have been made. I further agree that this Agreement shall be construed in accordance with the laws of the Commonwealth of Massachusetts. If any of its terms or provisions shall be held illegal, unenforceable, or in conflict with any law, the validity of the remaining portions shall not be affected thereby to the fullest extent permitted by law. I further state that I agree that I, my child and our respective estates, heirs, administrators, personal representatives, and assigns shall be bound by the same. SIGNATURE OF PARENT/GUARDIAN PARENT/GUARDIAN PRINTED NAME Please fill out all payment information and return with signed release and 2018 application.

5 LAST NAME FIRST NAME M.I. OF BIRTH / / AGE years months GENDER M F BLOOD PRESSURE HEIGHT WEIGHT PHYSICAL AND IMMUNIZATION / REQUIRED FORM Phone: / Fax: camps@babson.edu Jim Castrataro, Director USE THIS FORM IF ONE IS NOT PROVIDED BY YOUR PHYSICIAN. Must be returned no later than May 31, Camp will photocopy this form for emergency purposes only. IMMUNIZATION HISTORY Please record the date (month and year) of basic immunizations and most recent booster doses. Vaccines Month/Year Month/Year Month/Year Month/Year Month/Year DPT (Diphtheria, Pertussis, Tetanus) TD (Tetanus, Diphtheria) Tetanus Polio MMR (Measles, Mumps, Rubella) Hepatitis B Varicella (Chicken Pox) Hib (Haemophilus influenza) Tuberculin Test Results Lead Test Results Other CHECK IF NORMAL OR GIVE DETAILS Eyes Vision Skin Throat Ears Hearing Teeth Heart KNOWN ALLERGIES AND TREATMENT Lungs Posture Musc/Skel CNS Genitalia Menstruation Hernia Abdomen Food Medication(s) Environment Insect(s) Is the person currently under the care of a physician? Yes No If yes, why? Current medications or treatment Recommend/Describe any limitations or restrictions on camp activities Medications to be taken/administered at camp: (including sunscreen, inhalers, or the like) Name of Medication(s) MEDICATION POLICY Please list ALL prescription medication, and any over-the-counter or nonprescription drugs, taken routinely. A sufficient supply of medication (enough to last the entire enrollment at camp) must be brought to the nurse. Please remember to keep the medication in the original, packaged container that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. A Medical Authorization Form must be signed by the parent. Additional health information I have examined this child herein described and it is my opinion that this child is able to engage in and participate in all camp activities, unless otherwise noted above. Licensed physician s signature Address Telephone Examination date (Must be within 24 months of start date of camp)

6 AUTHORIZATION TO ADMINISTER MEDICATION TO A CAMPER This form should be filled out if your child will be taking medication while at camp. (To be completed by parent/guardian and countersigned by Babson s health-care consultant) NAME OF CAMPER FOOD/DRUG ALLERGIES DIAGNOSIS (AT PARENTS DISCRETION) AGE PARENT/GUARDIAN NAME HOME PHONE BUSINESS PHONE CELL PHONE EMERGENCY PHONE NAME OF LICENSED PRESCRIBER BUSINESS PHONE EMERGENCY PHONE NAME OF MEDICATION ROUTE OF ADMINISTRATION ORDERED QUANTITY RECEIVED SPECIAL STORAGE REQUIREMENTS SPECIAL DIRECTIONS (E.G., ON EMPTY STOMACH/WITH WATER) SPECIFIC PRECAUTIONS POSSIBLE SIDE EFFECTS/ADVERSE REACTIONS OTHER MEDICATIONS (AT PARENTS DISCRETION) LOCATION WHERE MEDICATION ADMINISTRATION WILL OCCUR DOSE GIVEN AT CAMP FREQUENCY DURATION OF ORDER EXPIRATION OF MEDICATIONS RECEIVED I hereby authorize The Camps at Babson College to administer to my child,, the medication(s) listed, in accordance with 105 CMR CMR (A) Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over-the-counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. 105 CMR (C) Medication shall only be administered by the health supervisor* or by a licensed health-care professional authorized to administer prescription medications. If the health supervisor is not a licensed health-care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health-care consultant. Medication prescribed for campers brought from home shall be administered only if it is from the original container, there is written permission from the parent/guardian, and the health-care consultant approves in writing the administration of the medication. 105 CMR (D) When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. * Health supervisor A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications, and is under the professional oversight of a licensed health care professional authorized to administer prescription medications. SIGNATURE OF PARENT/GUARDIAN HOME PHONE SIGNATURE OF HEALTH CARE CONSULTANT (To be signed by the Babson College Summer Camp s health care consultant)

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