Student Participant Information Packet

Please fill out the following form to ensure participation in MEarth programs. You must submit one form for EACH student (under 18 years old) participant in the program.

Participant Name*

First Last

Participant Address*

Street Address Address Line 2 City State ZIP Code

School, Program Affiliation, or how you learned about MEarth (e.g. CUSD, Boys and Girls Club, The Village Project, etc.)*

Gender*

Birth Date*

Age*

Height*

Weight*

Ethnicity

Parent/Guardian 1 Name*

First Last

Parent/Guardian 1 Phone*

Parent/Guardian 1 Email*

Parent/Guardian 2 Name

First Last

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Emergency Contact Information

Emergency Contact 1 Name*

First Last

Emergency Contact 1 Phone*

Emergency Contact 2 Name

First Last

Emergency Contact 2 Phone

Pick Up Authorization

We will release your child(ren) ONLY to parents/guardians and emergency contact persons – as well as persons authorized by you to pick up your child(ren). Please list below. We will check identification as necessary. Staff will review pick up information with you daily, during drop off.

Name 1*

First Last

Relationship 1*

Phone 1*

Name 2

First Last

Relationship 2

Phone 2

Name 3

First Last

Relationship 3

Phone 3

Campers must be signed in and out each day, every day of the program.
We will NOT release your child to an unauthorized individual for any reason. Only authorized adults (18+ years) on the Pick-Up Authorization list may sign out campers.
Late pick-up will incur a fee of $10 per 15 minutes.

SICK POLICY
Children will be sent home if any of the following conditions apply, and may not return for 24 hours until after the symptoms have stopped unless accompanied by a doctor's note:

Fever over 100 degrees
Bout of vomiting or diarrhea
A rash in a contactable area
Oozing and redness in the eye
Signs and symptoms of the flu or COVID-19
We will contact the parent/guardian if there are ANY questions or concerns about a child’s health while in our care.
MEarth reserves the right to refuse service to anyone if there is a question or concern regarding the health and well-being of a child to ensure a safe, healthy environment for all the children in our care.

BEHAVIOR EXPECTATIONS
Please review the following items with your child.

Arrive on time, or 10-15 minutes early, ready to participate
Adhere to sanitation procedures
Ask questions
Be engaged
Try something new
Be respectful of all life
Have fun!

Due to the importance of safety in our day program, the staff requires the right to discipline any and all campers who display inappropriate or unsafe behavior. The following is our discipline policy:

Verbal warning
Time out of activity (including, but not limited to field trips)
Parent/Guardian called
If a child continues to misbehave, the camper will be dismissed from camp, and NO REFUNDS WILL BE GIVEN. MEarth reserves the right to dismiss anyone from camp.
At NO TIME will physical punishment be allowed.

LUNCHES/FOOD
Please pack a lunch for your child, including any snacks and a refillable water bottle.
In the spirit of MEarth and sustainability, please aim for a zero-waste lunch by using reusable containers as much as possible.

WHAT TO WEAR
Please be sure to dress your child in layers and with a coat, rain jacket, and/or rain boots when rain may be in the forecast. *Should you lack access to these outdoor attire items, please contact [email protected].*
Comfort and safety is the key.
Closed-toed shoes are required.
Shorts, jeans, long pants, and t-shirts are acceptable. Layers are recommended.
A hat is highly recommended.
Apply sunscreen to your camper before leaving home. Staff and campers CAN NOT share sunscreen due to the risk of allergic reaction. Please provide YOUR child with his/her/their OWN sunscreen. Staff may not apply sunscreen on campers, but they will assist the campers in self-application.

PERSONAL BELONGINGS
Label ALL clothing, lunch, and other items your child brings to camp. Please make sure his/her/their personal items return home with them. MEarth staff and volunteers are not responsible for any lost or stolen items.
Campers are not allowed to bring personal items to camp (electronic games, cell phones, iPods, toys, etc.). Staff will take these items and hold them until the end of the day.

LOST AND FOUND
Lost and Found will be in the Green Building. Unlabeled found items will be collected in this Lost and Found bin every day.
MEarth will dispose of any unlabeled items left in the Lost and Found at 4:00 pm on the last day of camp.

Participant Liability Waiver

I hereby certify that the camper is my child, or I am their legal guardian and that their birthdate is correctly stated in the form above.

I understand and acknowledge that activities at MEarth Camp, such as hiking and working with tools, pose risks to my child, including risks of cuts, strains, sprains, sunburn, insect bites and serious injury or death.

I hereby certify that to the best of my knowledge and belief said minor is in good health and physically fit to participate in all camp activities.

I have received, read, and understand the MEarth Rules & Regulations and have reviewed them with my child.

As a parent or guardian of the above named minor, do hereby, for my child, myself, my heirs, executors and administrators, release and forever discharge MEarth and all officers, directors, employees, agents and volunteers of the organization, acting officially or otherwise, from any and all claims, demands, actions or causes of action which in any way arise from the minor’s participation in the MEarth School Break Camps.

eSignature for Participant Liability Waiver*

Media Release

Occasionally, MEarth program activities may be photographed, videotaped, or audiotaped for our nonprofit’s educational, publicity, or fundraising purposes. Please indicate if you give permission for your child to appear in videos, photos, or audio recordings without compensation (e.g., as part of brochures, slide shows, social media, or program websites).

I understand I may rescind my permission at any time. This change must be communicated in writing to MEarth

YES, I give my permission.

NO, I do not want my child to appear in any photographs, audio, or video.

I have carefully read this form and fully understand its contents. I have marked all responses and signed of my own free will.

eSignature for Media Release*

Name of Child's Physician*

First Last

Phone*

Name of Insurance Company*

Group/ID Number*

In case of emergency, take my child to:*

Nearest Hospital

Other

Emergency Release

I, undersigned, as a parent or legal guardian of the child named above, hereby consent to the administration of the minor first aid by MEarth and its delegated staff and directors.

If, in the judgment of MEarth Staff, the child named above needs immediate care and treatment as a result of any illness or accident, I do hereby request, authorize, and consent to such care and treatment as may be given to said child by any medical personnel or school representative. I request, authorize, and consent to whatever x-ray, examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of the medical staff of the hospital or facility furnishing medical or dental services.

It is further understood that the undersigned will assume full responsibility for any such action, including payment of costs. I do hereby agree to indemnify and hold harmless MEarth (including its officers, directors, staff, and/or volunteers) from any claim by any person whomsoever on account of such care and treatment of said child.

I understand that typing my name below will act as my electronic signature.*

Refusal To Consent

As the parent or legal guardian of the above named child, I do not give my consent for any emergency medical treatment. In the event of illness or injury requiring medical treatment, MEarth is not to take any action until I am contacted. I understand that withholding medical treatment from said child could have serious consequences to their health and well-being.

I do hereby agree to indemnify and hold harmless MEarth (including its officers, directors, members, and/or volunteers) from any claim by any person whomsoever as is related to no care and treatment being administered to said child.

Sign this section only if you DO NOT give your consent to treatment. I understand that typing my name below will act as my electronic signature.