Moir Park Camp Registration I have completed an application and been accepted into the City of Bloomington's fee assistance program.*yesnoOnly families that have been pre-approved for the fee assistance program may apply. If you have not yet applied you can apply here: https://www.bloomingtonmn.gov/pr/fee-assistanceCamper's Name* First Last Camper's Age (must be 8 - 14 years old to apply)*Camper's must be ages 8-14 to apply! Camper's Age not Appropriate for Summer Adventure Camps!We're sorry our programs are not designed for the camper's age and they should not register.Camper's Gender Identification (click as many as you like!) Female Male Non-Binary Trans Cis Other Camper's Friends or Sibling Preferences*List friends or siblings who might be at camp that your camper would like to be in the same group with!Camper's School*First Parent's Name* First Last First Parent's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country First Parent's Phone*First Parent's Email* Second Parent's Name First Last Second Parent's PhoneSecond Parent's Email Insurance CarrierGroup Policy NumberAllergiesIf camper has allergies describe all allergens, all allergic reactions and any medication (i.e. epipen, benadryl) that need to be administered.Physical / Medical ConditionsDoes the participant have any physical or medical conditions that could result in an emergency or preclude them from engaging in certain activities?MedicationsPlease list all medications (including over-the-counter or nonprescription drugs) taken routinely.Social and Emotional Wellbeing Is there anything else our instructors need to know about the participant that would help us provide the best experience for them?INDEMNIFICTION and RELEASE of CLAIM AGREEMENT* I have carefully read this agreement and understand it to be a release of all claims and causes of action for myself and/or my children's injury, illness or death and damage to my property that occurs while participating in the described program.In Consideration of myself and/or the children I am now registering being allowed to participate at Adventures in Cardboard, I the undersigned, on my own behalf and on the behalf of my children, acknowledge, appreciate and agree to the following conditions: 1) I represent that I am the parent or legal guardian of the children I am now registering. 2) I agree that I and/or my children shall comply with all stated and customary terms, posted safety signs, rules and verbal instructions as conditions for participating in Adventures in Cardboard’s activities. 3) I am aware that there are inherent risks associated with participation in camp activities and I, on behalf of myself and on the behalf of the children I am registering today, knowingly and freely assume all such risk, both known and unknown, including those that may arise out of the negligence of staff and other camp participants. I hereby allow my children to participate in the day camp activities. I do hereby release, discharge, and hold harmless Adventures in Cardboard, its employees, volunteers, agents and assigns from any and all claims, demands, rights and/or causes of action whatsoever kind or nature arising from or by any reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, loss and/or damage to property, and the consequences thereof resulting or which may result from myself and/or my children participating in the camp activities. 4) I understand that all participants are expected to follow directions and be safe while at Adventures in Cardboard. It is particularly important that participants stay with the group to ensure they are being supervised. If my children are creating conditions that may harm themselves or another participant, Adventures in Cardboard reserves the right to require my presence during camp activities. If behaving in way that is danger to self or others and in instances of extreme or repeatedly disobeying staff directions, Adventures in Cardboard reserves the right to dismiss myself and/or my children from the rest of a camp session without a refund. 5) I give my consent for the personnel of Adventures in Cardboard to secure emergency medical care and/or first-aid treatment, for myself and/or my children named above, as emergency conditions might require while under supervision of said personnel. I authorize the Adventures in Cardboard staff or their agents to arrange transport of myself and/or my children to a healthcare facility for emergency services as needed. 6) In the rare event of unusually dangerous weather I accept that Adventures in Cardboard may cancel camp in the interest of my and/or my children's safety, without a refund or scheduled make-up day. I recognize that the call to cancel camp for the day will be based on weather information available by 7:15am on the day in question. Cancellations will be posted on the Adventures in Cardboard registration page by 7:30am and calls made to families by 8:30am. 7) I give my permission for my children to participate in walking trips throughout the trails, fields, shorelines, streets and parks that are adjacent to the parks we are operating in during the weeks of camp you signed up for. 8) I hereby acknowledge that Adventures in Cardboard will assume that either parent of the children may pick up the children at any time during the program unless there is pertinent court documentation on file that indicates otherwise. 9) If my children have allergies or other medical conditions and I expect that it may be necessary for Adventures in Cardboard to give my children medicine during camp, I will indicate this in the Health History Questionnaire above and send the medicine to camp with my children. I will provide a list of the medications with detailed instructions on administration of the listed medication. 10) I hereby grant to Adventures in Cardboard the right to use and publish photographs of myself and/or my children, or in which we may be included, for website design, editorial, trade, merchandising display and advertising for the purpose of promoting the activities of Adventures in Cardboard; to alter the same without restriction and to copyright the same. I hereby release Adventures in Cardboard from all claims and liability relating to said photographs. 11) I understand that refunds can only be issued up until 14 days before the session in question begins or after April 30th for Summer Adventure Camps, whichever comes first. Refunds that are issued will be issued minus a processing fee. EMERGENCY CONTACT POLICY* I have read and agree to the Emergency contact policy below.The information requested is intended to help us in the event of an emergency. This information will alert us to potential problems, special needs or accommodations that might be required. By Program Policy, all of the information is confidential and made available only to staff. This health history is correct and complete as far as I know. The persons herein named have permission to engage in all camp activities except as noted. Further, it is my intention that the appropriate representatives of the camp be treated as “personal representatives” for the purposes of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996. I hereby agree (pursuant to 45 CFR § 164.510(b)) to the disclosure to camp representatives of the protected health information of the persons herein described, as necessary: (i) to provide relevant information to the camp representatives related to the persons’ ability to participate in camp activities; and (ii) in the case of minors, to provide relevant infor-mation to the camp representatives to keep me informed of my children’s health status. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the per-sons named above. This completed form may be photocopied for trips out of camp.COVID 19 RELEASE* I have carefully read this agreement and understand it to be a release of all claims and causes of action for myself and/or my children's and/or any of my relatives injury, illness or death that stems from myself and my children participating in the described program.I understand that anywhere people are present there is an inherent risk of exposure to coronavirus and I understand that it is expected that I keep my child away from camp if they are running a fever, show symptoms of COVID 19 or other transmissible illness or if they or someone they live with tests positive for COVID 19. I submit to my child's temperature being taken at camp and understand that the expectation will be for me to keep my child away from camp if they are running a fever. I acknowledge the contagious nature of COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that Adventures in Cardboard LLC has put in place preventative measures to reduce the spread of the COVID-19. I further acknowledge that Adventures in Cardboard LLC can not guarantee that my child and those they live with will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by the coronavirus may result from the actions, omissions, or negligence of my children and others, including, but not limited to staff, other clients, their families and their children. I voluntarily seek services provided by Adventures in Cardboard LLC and acknowledge that I am increasing the risk to exposure to coronavirus of myself, my children and my family. I acknowledge that my children must comply with all set procedures to reduce the spread while attending camp. To this end I also attest that: 1) My children are 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. 2) They have not traveled internationally within the last 14 days. 3) I have not traveled to a highly impacted area within the United States of America in the last 14 days. 4) I do not believe they have been exposed to someone with a suspected and/or confirmed case of COVID-19. 5) They have not been diagnosed with COVID-19 and not yet cleared as non contagious by state or local public health authorities. 6) That I and my children are following all CDC recommended guidelines as much as possible and limiting our exposure to coronavirus/COVID-19.