Summer Camp Waiver & Release

Child Name: _____________________________ Birth Date: ___________ Age: _____ Sex: M F Grade:________

Child Name: _____________________________ Birth Date: ___________ Age: _____ Sex: M F Grade:________

Child Name: _____________________________ Birth Date: ___________ Age: _____ Sex: M F Grade:________

Home Address:____________________________________________________________________________

City:____________________________ State:_____________ Zip:___________________

E-Mail Address:______________________________________________________________________

Mother’s Name:_____________________________ Father’s Name:_______________________________

Cell Phone #:_______________________ Cell Phone #:________________________

Mother’s Employer:__________________________ Father’s Employer:____________________________

Work Phone #:_______________________ Work Phone #:_______________________

Please PRINT Legibly and Complete ALL Sections.

Emergency Contact :________________________ Phone #:____________________ Relation:_______________

Persons Authorized to Pick Up: (In addition to parents/guardians)

Name #1:_____________________ Name #2:_____________________ Name #3:_____________________

Phone #:_____________________ Phone #:_____________________ Phone #:_____________________

Relation: ____________________ Relation: ____________________ Relation: ____________________

(other than parent listed)

Does your child take any medication? : ___________________________________________________________

Will medication need to be administered by staff? YES or NO

If yes, please list the medical condition for which it is taken:___________________________________________

Does your child have any know allergies:__________________________________________________________

Is your child living with ADD, or ADHD, or Other Special Circumstances we need to be aware of:

___________________________________________________________________________________________

Does your child have any disabilities, behavioral or emotional issues that we need to be aware of:

___________________________________________________________________________________________

Help Us Provide the Best Care by Making us Aware!

Emergency Contact and Persons Authorized to Pick Up

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Waiver and Release of Liability & Assumption of Risk

Applicant’s Name(s): (1)____________________________________ (2) ____________________________________

(3) ____________________________________ has my permission to participate in the North Myrtle Beach Aquatic & Fitness

Center Summer Camp Program. I/we understand what the aforementioned activity involves and believe that the

aforementioned person is in proper physical condition to participate. I/we assume all risks and hazards incidental to the

conduct of the aforementioned activity. In consideration of your accepting my entry, I hereby for myself, my child, my heirs,

executors and administrators, waiver and release any and all rights and claims for damages I or my child may have against the

Summer Camp Program, NMB Aquatic & Fitness Center, City of North Myrtle Beach Parks and Recreation Department and

its representatives, successors and assigns for any and all injuries or illness, including but not limited to, personal injury, (ex.

Communicable disease, MRSA, influenza, COVID-19), suffered by myself or my child at any activity sponsored by these groups.

I also give permission to the City of North Myrtle Beach to use and display any photographs taken of me/my child, which may

be forwarded to newspapers and other publications in which the photograph would be associated with the City of North

Myrtle Beach. In the event of an emergency requiring medical attention beyond first aid, I/we hereby grant permission to a

physician or hospital personnel designated by the North Myrtle Beach Aquatic and Fitness Center Summer Camp Program and

staff to provide medical emergency attention to the aforementioned person including hospitalization. Any expense from

injury or illness is the responsibility of the parental insurance company.

Date_________________ Name (Parent/Guardian)__________________________________

Signature (Parent/Guardian)

T-Shirt Size (Circle Appropriate Size/Sizes):

YM YL AS AM AL AXL

Shirts will be handed out at a later date.

Camper AFC Member: Camper AFC Non-Member:

Late Pick-Up Policy

We close promptly at 5:30pm.

For all children not picked up by the end of the program the following late policy will be in effect:

5 minutes after the designated pickup time the parent/legal guardian will be called. If the parent/legal guardian

cannot be reached, we will call from the child’s authorized emergency contact list.

A late fee will be charged to parents of children picked up after 5:30pm in the amount of:

Payment is due at the Front Desk at the time of pickup.

Continued disregard for the pick-up time is cause for child’s termination from the Camp Summer Blast Program.

1st Late Pickup $1.00/minute

2nd Late Pickup $2.00/minute

3rd Late Pickup $5.00/minute

4th Late Pickup Meeting with Director