Emergency Contact, Medical Info, and Releases Emergency Contact, Medical Info, and Releases Form Step 1 of 2 50% Child(ren)'s Name(s)*To add additional children, click the plus sign on the right. Please include a preferred name or nickname for children when applicable.NameDate of BirthGenderSchool Child(ren) Lives With*Both parentsOne parent only (please specify)Other (please specify) Parent / GuardianIf parents are divorced or separated, please specify custodial parent.First Parent/Guardian*At least one phone number and email required.NameRelationship to ChildWork PhoneCell PhoneEmail Second Parent/GuardianAt least one phone number and email required.NameRelationship to ChildWork PhoneCell PhoneEmail Emergency ContactsPlease list two relatives or nearby neighbors that you have notified and who have agreed to assume temporary care of your child if you cannot be reached.Emergency Contact #1*Phone number requiredNameRelationshipPhone Emergency Contact #2*Phone number requiredNameRelationshipPhone Authroized to PickupPlease list all persons that you authorize to pickup your student from afterschool.Authorized Individual #1*Phone number requiredNameRelationshipPhone Authorized Individual #2Phone number requiredNameRelationshipPhone Authorized Individual #3Phone number requiredNameRelationshipPhone Authorized Individual #4Phone number requiredNameRelationshipPhone Code Word*Please select a code word that you will share with those persons authorized to pick up your child(ren). The code word and/or proof of identification (driver’s license) may be asked for at pickup time. Medical InformationDoctor & Insurance*If insured, please include insurance information.Doctor's NameDoctor's PhoneChild's WeightChild's HeightMedical Insurance CompanyMedical ID No. MedicationsIf your child routinely takes medication, please fill out the following, even if the medication is not dispensed during Mountain SOL programs. Any medication needed during the program should be given to a designated staff member and will be dispensed by the designated staff member. Please list the following information for each medication (click on the plus sign on the right to add medications).MedicationDosage/How OftenPrescribing Doctor Medical Authorization* I authorize staff to assist in the dispensing of medication including epi-pen and inhalers, as prescribed above My child does not require medication Sunscreen & Insect Repellent Authorization*Since we are outdoors, sunscreen and insect repellent are important for your child's protection. We need your permission to use sunscreen and insect repellent on your child. If you do not authorize Mtn SOL, please provide your child with their own sunscreen and insect repellent. Yes, I authorize the use of sunscreen and insect repellent. No, I do not authorize the use of sunscreen and insect repellent. Student Photographs and Video*May we take photographs and/or videos of the student, to be used as promotional material for Mountain SOL School? May we include their name? Yes Yes, but no name No Additional Health Information*Important: Please describe any special health considerations including, but not limited to ALLERGIES or physical conditions that may affect your child's participation in our programs (please list "none" if this does not apply). Please be specific about any allergies the child has and if the allergy requires an Epi-Pen (or similar).Additional Child Information*Please describe any behavioral or circumstantial issues that staff should be aware of that may affect your child's participation in our programs. Are there certain things that would be helpful to know about your child? Likes/dislikes, change in family circumstances, fears, etc (or note "None").Medical Form & Permission to Treat*My child is in good physical and mental health. I have listed any special health considerations. I acknowledge that acceptance of my child to the program with my child's special health considerations is at the discretion of Mountain SOL School. In case of emergency, I understand that every effort will be made to contact parents or guardians of children. In the event I cannot be reached within a reasonable time, I grant permission to the physician selected by Mountain SOL staff to hospitalize, secure treatment for and to order injection, anesthesia or surgery for the child as named herein. By checking this box, I hereby certify that the above information is correct. Release of Liability and Hold Harmless*I authorize my child to participate in the program and any associated transportation services provided by Mountain SOL School or its agents. I acknowledge that I am the only one who can determine if I or my child is physically fit enough or adequately skilled enough to participate in the program. I acknowledge the inherent risks that may result from by child’s participation in the program including falls, fractures, contraction of infectious diseases, misbehavior of other children, etc., all of which may result in injury or death to my child or damage to his/her/our property. I further acknowledge that Mountain SOL School is neither a common carrier nor in the business of providing transportation services to the public. I expressly assume these risks and any associated costs, damages or losses, including those caused by simple negligence of Mountain SOL School, and waive and fully release all claims held by me, my spouse/partner, my child or any of our estates from and against Mountain SOL School and its agency partners, officers, board members, agents, employees, volunteers and representatives, arising from my child’s attendance and participation in the program and accept full responsibility for the cost of all medical treatment to my child as a result of any injuries caused by or through such other risks. This waiver and release will apply to any and all actions, causes, damages, claims or demands of any kind, whether known or unknown, arising out of or otherwise incidental to participation in the program. I further agree, on behalf of myself and/or my child, to indemnify, defend and hold harmless Mountain SOL School and its agency partners, officers, board members, agents, employees, volunteers and representatives from any injuries, liabilities, claims, damages and expenses, including attorney fees, incurred by Mountain SOL School, me, my child or on behalf of my child, arising from my child’s attendance and participation in the program, with the exception of gross negligence or reckless misconduct of Mountain SOL School. While participating in the program, I and my child will obey all rules, regulations and laws of the State of West Virginia and the United States. I and my child will further obey all rules, regulations and policies of Mountain SOL School associated with the program. I acknowledge that my or my child’s failure to comply with these rules, regulations, policies and laws may result in my or my child’s expulsion from the program. I agree that this release will be governed by the laws of the State of West Virginia. If any provision of this release is found to be invalid or unenforceable, then the remainder of this release will have full force and effect, and the invalid provision will be modified, or partially enforced, to the maximum extent permitted by West Virginia State law. By checking this box, I hereby certify that this information is correct. I have read all of the above terms and conditions, and I understand and agree to be bound by them. COVID-19 Release*I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Mountain SOL/Aurora Lights has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Mountain SOL/Aurora Lights can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, school staff, and other school clients and their families. I voluntarily seek services provided by Mountain SOL/Aurora Lights and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment. I attest that, for any time the student is attending Mountain SOL classes: * The student is not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * The student has not traveled internationally within the last 14 days. * The student has not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe the student has been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * The student has not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities. * I and my student are both following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Mountain SOL/Aurora Lights harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the school, or that may otherwise arise in any way in connection with any services received from Mountain SOL/Aurora Lights. I understand that this release discharges Mountain SOL/Aurora Lights from any liability or claim that I, my heirs, or any personal representatives may have against the school with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Mountain SOL/Aurora Lights. This liability waiver and release extends to the school together with all owners, partners, and employees. By checking this box, I hereby certify that this information is correct. I have read all of the above terms and conditions, and I understand and agree to be bound by them.