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There Will Be a Late Fee of $15 for Payment After This Date
Please use Format (111)123-1234
If you check “NO” give specific instructions on this page for the camp to follow if you or the person designated cannot be located. In case of serious accident or illness, we attempt to contact you in order to explain the situation and let you decide what is to be done. Occasionally we cannot locate the individuals listed on the form. This is the reason we ask for your permission to take your child to the hospital when it seems necessary.
Children are transported to the hospital by the Mayfield Heights Fire Department Paramedics. The Paramedics cannot remain at the hospital nor bring the child back. This is your responsibility. If we cannot locate you to accompany your child, a counselor will accompany your child and the Paramedics to the hospital. Mayfield Heights Recreation does not provide insurance for campers. Each participant must provide his/her own insurance.No refunds after June 9, 2020. If a child is withdrawn from camp before camp begins, $15 will be retained by the City of Mayfield Heights to cover administrative costs.
Note: Permission is granted for my child, if registered, to take scheduled Field Trips with the camp under the supervision of the Mayfield Heights Recreation Department.
It is very important to the Mayfield Heights Day Camp Staff to know who is picking your child/children up from camp. Please list below the names of the people who have permission to pick up your child/children. If there is a day when someone other than those listed below will be picking up your child, please send a note that day and give it to your child’s counselor.The following listed people have permission to pick up my child:
Assumption of Risk and Waiver of Liability Relating to Coronavirus/COVID-19
The novel coronavirus, COVID-19, has been declared to be a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments, as well as federal, state and local health agencies, recommend social distancing and have, in many locations, prohibited the congregation of groups of people.
You have indicated you wish to participate in the Day Camp Program sponsored by The City of Mayfield Heights (the “City”). The City has put in place preventative measures to reduce the spread of COVID-19; however, the City cannot guarantee that you or your dependents will not become infected with COVID-19 while participating in activities sponsored by the City, including day camps. Further, participating in day camp activities sponsored by the City could increase your risk and your dependents’ risk of contracting COVID-19.
By signing this document, you acknowledge the contagious nature of COVID-19 and you voluntarily assume the risk that you and your dependents may be exposed to or infected by COVID-19 by participating in activities sponsored by the City, and that such exposure or infection may result in personal injury, illness, permanent disability and death. You understand that the risk of becoming exposed to or infected by COVID-19 by participating in activities sponsored by the City may result from the actions, omissions, or negligence of yourself and others, including, but not limited to City employees and volunteers, and program participants and their families.
By signing this document, you voluntarily agree to assume all of the foregoing risks as part of the participation, and to accept sole responsibility for any injury to your dependents or yourself (including but not limited to, illness, personal injury, disability, and death) of any kind, that you or your dependents may experience or incur in connection with your participating in activities sponsored by the City.
By signing this document, you agree: On my behalf, and on behalf of my dependents, I hereby release, covenant not to sue, discharge, and hold harmless the City, its employees, agents, and representatives, of and from any and all claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to such activities sponsored by the City. I understand and agree that this Waiver includes any claims based on the actions, omissions, or negligence of the City, before, during or after participation in any activity sponsored by the City.
By signing below you acknowledge the above provided information is accurate and complete for you camper and agree to all terms listed in the information provided including the Day Camp Handbook. As a participant in this and any other program of the Mayfield Heights Parks and Recreation Department, I, for myself or the participant for whom I sign (if under 18 years of age), recognize and acknowledge that I/we may be exposed to a variety of risks and I/we agree to assume all such risks, including but not limited to, any damage resulting from physical injuries, death, loss of services or consortium, loss or damage to property, or any other loss or injury I/we may sustain as a result of participating in any and all activities connected or associated with such programs. I acknowledge that I/we have no physical limitations, or disabilities of any kind which would restrict me/us from participating. Any special accommodations needed have been noted or will brought to the attention of the Mayfield Heights Parks and Recreation Department
In consideration of the Mayfield Heights Parks and Recreation Department accepting my/ our registration and with the intent to be legally bound, I hereby, for myself or the participant for whom I sign (if under 18 years of age) and all heirs, executors, administrators and assigns: (1) forever release, waive and relinquish any claim I/ we have or may have as a result of participating in this and all other programs of the City of Mayfield Heights Parks and Recreation Department; and (2) promise not to sue and agree to hold harmless and defend, the City of Mayfield Heights and its officers, officials, agents, employees, volunteers, independent contractors, and other representatives (referred to collectively hereinafter as “City of Mayfield Heights”) from any and all claims, liabilities, demands, actions or causes of action in any way resulting from my/our participation in this and all other programs of the Mayfield Heights Parks and Recreation Department.
Use of Photographs: I do hereby grant and give the City of Mayfield Heights the right to use my photograph or image (or the photograph or image of the participant for whom I am signing) with or without my/our names, both single and in conjunction with other persons or objects for any and all purposes including, but not limited to, private or public presentations, advertising, publicity and promotion relating hereto. I warrant that I have the right to authorize the foregoing uses and do hereby agree to hold the City of Mayfield Heights harmless of and from any and all liability of whatever nature, which may arise out of result of such uses.Please read carefully, by signing you waive certain legal rights.
Parent/Guardian (if participant is under 18 years old)
This field is not part of the form submission.
* indicates a required field