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1 LKESIDE DY MP pplication for Traditional and dventure amp To register, return completed application (s 1-10), special event waivers and permission slips, and all payments due for the first week of camp (camp tuition, special event fee, and optional meal ticket). Refer to DUE DTE SHEDULE and ONDITIONS OF REGISTRTION for complete details. Registration is on a first-come first-serve basis. Submitting this form DOES NOT guarantee a space. Please use a separate application form for each child. hild s last name First name Street address P.O. Box ity State Zip Phone Grade completed as of June 16 Birthday / / ge Male or Female How referred to Lakeside Postcard Baltimore s hild Friend Other First Year Enrolled? Y / N lub Member: Y / N Member #: Swim Level of camper if known: Program where swim lessons were taken: ode Word (to be used by anyone other than parent or guardian who is picking up the child) Parent/Guardian ddress Phone (H) Phone (W) ell phone address PRENT INFORMTION Parent/Guardian ddress Phone (H) Phone (W) ell phone address 2 amp friend request (must be the same age): 1 2 (Sorry no guarantees) 3 Remove application carefully MPER HELTH HISTORY Emergency contact (other than parent) Phone (H) (W) Doctor Phone Date of last physical exam Must be within the last 2 years // Info required by state Insurance arrier Policy Number MPER IMMUNIZTION INFORMTION This information is required before registration is complete or a child is admitted to day camp. Physician may fax the information to ll campers must be current on all immunizations, see (Immunization) 1. Provide date (month and year) of camper s last tetanus (or DTP) shot: 2. Is the camper currently enrolled in a Maryland school, public or private? YES, provide name of the Maryland school: NO, provide a copy of immunizations confirming that the child has received all immunizations as required by the Maryland DHMH Recommended hildhood Immunization Schedule. See (Immunization) for information. 3. Is the camper exempt from any immunization on medical or religious grounds? YES, provide a signed copy of Maryland Department of Health and Mental Hygiene Immunization ertificate from either a licensed physician indicating that the immunization is medically contraindicated, or the parent or guardian indicating that they object to immunizations for religious reasons. NO Health Information: Provide information on any medical conditions, psychological conditions, behavioral conditions, medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child s camp experience is positive:. (ny medication to be administered at Lakeside Day amp MUST be accompanied by a Physician s note explaining dosage) 4 ttach REQUIRED urrent Photo Schedule & Payment Receipt: you will be sent a confirmation letter of all payments and your child s camp schedule. Please review carefully and call the lub office if there are any questions

2 Week # dventure amp Option Meal Ticket SPEIL EVENT FEES OUNTING OFFIE ONLY Full Week commitment ONLY. omplete & return the attached Waiver agreements (2) with 7 & this form. OFFIE USE ONLY TOTL MT. DUE MP FEES MEL TIKET $ TOTL MT. PID EMPLOYEE INITILS HEK NO. or ash DTE RE. 5 Print amper s Name: Last Name First Name -- LKESIDE DY MP 2016 SHEDULE -- --FOR OFFIE USE ONLY-- G OFFIE USE ONLY Date Mon. Tues. Wed. Thurs Fri. Put a Y in each day attending Projected Y or N 1 6/13-6/17 Limited Enrollment 2 6/20-6/24 3 6/27 7/1 4 7/5-7/8 LOSED LOSED 5 7/11-7/15 Event 6 7/18-7/22 Tie Dye Shirt Week $ 7 7/25-7/29 8 8/1-8/5 Event 9 8/8-8/12 Event 10 8/15-8/19 Limited Enrollment 8:30am-5:30pm*** WIVERS REQUIRED 6 Traditional amp omplete steps 1-6, & 8-12 $ ertain dates above have Events. If your child will be in attendance for weeks 1, 2, 3, 8 & 10, there is an additional $5 fee; for weeks 4 & 7, a $17 fee; and weeks 6, two $5 fees. These additional fees must be included with the regular camp payments. See Waiver and Permission Slip insert for Red Zone trip week 4 and Rockin Jump trip week 7. lso, complete s 9 & 12. dventure amp Option omplete steps 1-5 & 7-12 Full Week ommitment (ages 9-13) Please put a Y in the dventure amp column and on each day of that week. If there is no Y in the dventure amp column, your child will be provided the Traditional amp for their camp experience. If you have selected the dventure amp option, please complete the following: I hereby authorize that my child may participate in the dventure amp (includes fees & courses in Zipline, rchery, Wall limbing, Laser Tag, Trampoline Park, Hiking, Swimming, Low Ropes, ir Rifle and other outdoor skills ). Parent Signature: *** Priority for week 10 will be given to persons who were enrolled for a minimum of 2 weeks before ugust 15th. Date of signature: See Lakeside Day amp/red Zone/Earth Trek/Rockin Jump Waivers and Permission Slip inserts. omplete, sign and return the two attached waiver agreements & permission slip (complete both sides of each) with this pplication & fees. HNGES/NELLTIONS POLIY I understand any changes to or cancellations of the pre-registered schedule must be made in writing, ed (robin@padoniaparkclub.com) or faxed ( ); please call to verify that your or the fax was received by the office. The request must be received and verified no later than 5:00pm. the Friday before two full weeks prior to the pre-registered week in question to apply monies already paid to available week (s) with openings and to get the desired changes. There is a $10.00 administrative fee for each change or cancellation to the pre-registered schedule. If the written cancellation is not received by 5:00PM. the Friday before two full weeks prior to the pre-registered week (refer to Due Date Schedule ), you are still liable for the total applicable camp fees and possible finance charges. ny approved refunds will be sent out in September. No refunds will be made for absences. (Please initial) Transportation Permission Slip/Waiver: I agree to allow my child to attend the following field trips that are 8 scheduled: dventure amp (Earth Treks, Red Zone, romwell Valley & Rockin Jump) & Traditional amp (Red Zone & Rockin Jump). Passenger approved busses or vans will be used as transportation. (Please initial) 9 EMERGENY MEDIL TRETMENT RELESE 10 I DO/DO NOT (circle one) authorize a physician or medical facility to treat my child/ward (circle one) for injuries sustained while at Lakeside Day amp in the 10 event that I am not able to be contacted for the consent of treatment. In signing this registration form below, I acknowledge having read and understood The onditions of Registration, General amp Information and the information on both sides of this form, state to the best of my knowledge that the health information is up-to-date and accurate and agree to bear full responsibility for my child while he/she is engaged in any activity of Lakeside Day amp. Signature of acknowledgement and acceptance by Parent or Guardian Date Welcome Packet Received 11 For Office Use Only 7 12 dventure & Traditional amp requirement: for Rockin Jump : REQUIRES ONLINE WIVER (complete and send asap) rockinjumptowson.pfestore.com/waiver in order for your child to participate. Forward waiver acknowledgement to camp@padoniparkclub.com

3 Waivers and Permission Slips >>>>>>>>> Traditional & dventure ampers hild s Name DOB: Traditional and dventure amp Red Zone dventures (RZ) Player Waiver and Permission Slip By signing this agreement, you agree that you have read and understand the following statements: (1) You agree to follow all posted rules and instructions of RZ staff. (2) Laser Tag is a physical activity that, like other physical activities, involves a risk of injury. Our arena is dimly lit, haze-filled, and full of obstacles, walls, platforms and ramps. Many people are in the arena at the same time, often moving quickly and quietly. While our arena is supervised, no part of the arena is supervised continuously. (3) You accept and assume all risk of injury from participation at RZ. (4) You recognize that medical conditions including asthma, epilepsy and seizure disorders and others can be exacerbated or triggered by Laser Tag play and all appropriate care should be taken if you have any such condition. (5) You release RZ and its owners(s), affiliates, members, managers and employees from all claims, liabilities and losses that may arise from your play or participation, except if arising solely from our gross negligence. (6) You will report any injury sustained at RZ as soon as practical, but no later than your departure. (7) You will indemnify, defend and hold harmless RZ and its owner(s), affiliates, members, managers and employees from any claims, liability, suits or damages made, alleged or suffered by anyone arising out of your activity or conduct at RZ. (8) If you are signing this as a parent or guardian on behalf of a minor, you agree to be bound by the terms of this Player Waiver and give consent such minor to participate in activities at RZ. (9) RZ may refuse admission to & eject anyone who fails to follow our posted rules or instructions or otherwise causes a safety hazard. (10) I agree to allow my child to be transported by passenger approved bus and attend the Red Zone field trip(s). Signature: (if under 18, adult parent or guardian MUST sign. Date Traditional & dventure ampers nd dventure & Traditional amp requirement: for Rockin Jump : REQUIRES ONLINE WIVER (complete and send asap) rockinjumptowson.pfestore.com/waiver in order for your child to participate. Forward waiver acknowledgement to camp@padoniparkclub.com LKESIDE DY MP dventure ampers ONLY Participant ssumption of Risk and Waiver greement Welcome to our dventure amp program with LKESIDE DY MP! The dventure amp is a powerful outdoor experience designed to foster self-discovery, confidence, teamwork, communication and group process skills. It is a carefully structured, graduated series of initiative events incorporating physical, mental and social challenges. ctivities include but are not limited to reliance on others or equipment, climbing over obstacles, target sports, and riding on our Zip Wire of heights up to 50 feet. We are confident you will find it a great learning experience; both fun and challenging. When working outdoors and leading physical activities, safety is our main concern. We will regularly discuss basic rules of safety and provide the special organization, supervision, instruction and equipment you need to participate safely in course activities. It is impossible for us to eliminate all risk, however, your commitment to follow instructions and use sound personal judgment will contribute greatly to your well being. By signing this waiver, the participant accepts that there are inherent risks and hazards in adventure programming and agrees to hold harmless hild are International, LTD., Lakeside Day amp, The Padonia orporation, and any of their heirs, assigns or successors known as Lakeside Day amp. Please read and sign the following agreement: I, as a participant, understand I will be involved in activities that require periods of physical exertion, balancing, heights (up to 20 ), lifting, pushing, pulling and climbing. I know most activities will be outdoors where I will need to watch for slippery and/or uneven footing, limbs and branches, insects or animals and possible exposure to extreme or inclement weather. I fully understand that my physical activity involves risk of injury. I understand the risks may include loss or damage to personal property. I understand that I will not be forced to do any activity and that despite a reasonable precaution taken by LKESIDE DY MP, that a guarantee of absolute safety is impossible. I agree to exercise good personal judgment, to ask for help if I am concerned about my safety and to be responsible for deciding if a proposed activity is appropriate for me. I have listed on the Medical History Page and informed my instructors of any physical, mental, or medical conditions, recent injuries, medication, allergies or other considerations that might limit my ability to participate or affect other members of my group. I realize that failure to disclose my information could result in serious harm to myself or others. I also state that I am not under, and will not be under the influence of any chemical substance including alcohol, medications or illegal substances. I agree to comply with safety instructions given by LKESIDE DY MP and to be responsible for my safety and well being. I agree to hold LKESIDE DY MP, its Directors, Owners, Officers, Employees, gents and/or ssociates harmless for any accidents, injury, loss of or damage to property that may occur in this program. I understand that all possible precautions are taken to insure that all programs and activities sponsored by LKESIDE DY MP are conducted by mature and qualified personnel in a safe and responsible manner. I voluntarily assume the risks of the activities and agree to report any injuries before leaving the premises. In the event that it becomes necessary, I give permission to LKESIDE DY MP to secure proper medical treatment. I understand that any medical expense not covered by LKESIDE DY MP medical insurance will be billed directly to me or to my insurance company. I have read and understand all materials outlining the adventure course, including this waiver and agree to abide by these terms. I am aware this is a waiver and release of liability and I sign it voluntarily. / Signature of Participant Printed Name Participant Date

4 dventure ampers Only Waivers and Permission Slips dventure ampers Only IMPORTNT Please be thorough in providing the information requested. Failure to disclose information could result in serious harm to you as a participant in this program. Please do not forget to read and sign the opposite side of this sheet. ll the information will be kept confidential. IF YOU HEK YES TO NY QUESTIONS BELOW, DESRIBE PROBLEMS IN DETIL ON THE RIGHT SIDE OF THE FORM. ttach an additional sheet if necessary. heck one Description 1. Yes_ No_ Do you have any present medical problems or physical limitation? (Describe) 2. Yes_ No_ Does your health prevent you from participating in any physical activities? 3. Yes_ No_ re you taking any prescription or nonprescription medications? (List all and reasons for taking) 4. Yes_ No_ Have you had any surgeries or been hospitalized for any reason? (Describe and give approximate dates) 5. Yes_ No_ re you allergic to any insect bite or medications? 6. Yes_ No_ Do you smoke? (If so how much?) 7. Yes_ No_ Do you have impairments of vision or hearing? 8. Yes_ No_ Have you ever been diagnosed as having high blood pressure? re you currently under treatment for high blood pressure? 9. Yes_ No_ Do you have heart murmurs, episodes of irregular heartbeat, shortness of breath or chest pain on exertion? 10. Yes_ No_ Have you ever been diagnosed as being at risk of heart disease? Is there any history of heart disease in your family? 11. Yes_ No_ re you engaged in a regular program of exercise? (Describe exercise and frequency) 12. Yes_ No_ Do you have asthma? (Describe) 13. Yes_ No_ Do you have diabetes, thyroid trouble or other endocrine problems? (Describe history & symptoms) 14. Yes_ No_ Have you had or do you have ulcers, heartburn or other intestinal disorders? 15. Yes_ No_ Have you ever had seizures? (Describe and give date of last seizure) 16. Yes_ No_ Do you have problems with your neck, back, arms, shoulders, ankles or knees that limit your activities? (Describe symptoms and limitation) The date of my last tetanus booster: My birth date is (MM/DD/YY): Persons to be contacted in case of serious illness or injury: Name, ddress, Phone Number & Relationship: Name of Insurance o.: Medical Insurance Plan Number Required of parents for dventure amper for Rockin Jump Field Trip (Trampoline Park) : REQUIRES ONLINE WIVER (complete and send asap) rockinjumptowson.pfestore.com/waiver in order for your child to participate. Forward waiver acknowledgement to camp@padoniparkclub.com

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6 dventure ampers Only dventure amper parents must complete and return this form with Lakeside Day amp Waivers & pplication