This is a secure form and registration will take approximately five minutes to complete.
Please note that
You will need your child's Medi-Cal/insurance information and COVID vaccination card. You must fill out a separate registration form for all participants. Thank you!
Only check here if you are a parent accompanying your child. Please also make sure you have filled out a separate registration form for your child.
I am a parent registering as a chaperone PARTICIPANT Information PARTICIPANT'S Name * Required
Note: you must fill out a separate registration form for each participant.
PARTICIPANT'S Date of Birth * Required PARTICIPANT'S Age * Required Select One 8 9 10 11 12 13 14 15 16 17 Adult (still in high school)
PARTICIPANT Details Grade Level for Incoming School Year * Required Select One 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
PARTICIPANT'S Gender PARTICIPANT'S Vision * Required Select One Totally Blind Light perception Legally Blind (20/200 or <20% field) Low Vision (20/70) T-shirt Size * Required Select One YOUTH Small YOUTH Medium YOUTH Large ADULT Small ADULT Medium ADULT Large ADULT XL ADULT 2XL ADULT 3XL Name of School School District Name of PARTICIPANT'S Teacher of the Visually Impaired
(O&M or VI Services)
Teacher's Email Address Teacher's Phone Does your child have any mobility impairments requiring staff assistance? * Required Please describe the mobility issue: Does your child have any allergies? * Required Please list allergies: Does your child have any medical issues/concerns? * Required Please list issues/concerns: Insurance/Vaccination Information Insurance/Medi-Cal information
Please upload a photo of your child's insurance/Medi-Cal card. If you are unable to upload, you can email this later.
COVID Vaccination or PCR Test Results I understand that any participants/guests without vaccination must either bring proof of a negative PCR test taken within 3 days of the trip or else agree to wear a mask for the duration of the activity. Proof of COVID Vaccination
If participant has had the Covid-19 vaccine please upload proof here.
Parent/Guardian Information Parent/Guardian 1 Name * Required
Parent's Email * Required
Phone (home) Phone (cell) Phone (work) Address
* Required Parent/Guardian 2
Check here to fill out information for a second parent/guardian
Parent/Guardian 2 Name
Phone (home) Parent 2 Email
Parent/Guardian 2 Address
Same as Parent/Guardian 1
Our programs remain free of charge thanks to private funding sources. Some funders ask for the following demographic information. This information will remain anonymous and used for reporting purposes only. Thank you for helping us report accurate information to our funders!
Ethnicity Total number of adults residing in your home? Total number of children residing in your home? What is your household’s combined gross annual income from all sources? Releases and Disclosures Activity Permission/Opt-Out * Required I have read and agree to the ACTIVITY PERMISSION/OPT-OUT:
I hereby grant participant named above permission to participate in all activities offered by or through Wayfinder Family Services, with the exception of those activities indicated above. The undersigned parent, guardian, or custodian of the above named participant hereby joins in the foregoing Activity Opt-Out Form and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend Wayfinder Family Services, their directors, officers, agents, employees, and volunteers from and against any claims, actions, demands, expenses, liabilities (including reasonable attorney fees) for negligence as a result of said participant’s participation in the activities of Wayfinder Family Services and his or her use of the property, animals, and facilities. I, on behalf of said participant, further agree not to sue Wayfinder Family Services, its directors, officers, agents, employees, and volunteers as a result of any injury that said minor suffers from negligence in connection with his/her participation in the activities of Wayfinder Family Services.
I represent that said participant has no health or physical condition that will interfere with the activities stated above or cause him/her to be more susceptible to injury than the average person. If any health conditions are present, I assume the risks associated with any such health or physical condition. Consent * Required I have read and agree to the AUTHORIZATION FOR TREATMENT OF ADULT CONSENT, RELEASE, AND COVENANT:
The undersigned parent/guardian represents to Wayfinder Family Services that the minor named in this application is in his and/or her legal custody and control; and that the undersigned desires said minor to participate in the programs of Wayfinder Family Services, and that for purposes of said participation the undersigned agrees, authorizes and states as follows:
In case of medical or dental need or emergency, I (we) understand every effort will be made to contact parents/guardians of children. In the event I (we) cannot be reached, I (we) undersigned, parents/guardians of camper, do hereby authorize Wayfinder Family Services and its officers or staff employees as agent(s) for the undersigned to obtain and consent to any x-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital care which is deemed advisable by, and is to be rendered to said minor under the general or special supervision of any surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said physician or dentist or at the said hospital.
I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves). We understand that no representation of such coverage exists or is intended by this form.
It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of Wayfinder Family Services (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem advisable. The authorization is given pursuant to the provisions of Sections 25.8 of the Civil Code of California.
This authorization shall remain effective while the child is enrolled in Wayfinder Family Services’ Recreation Programs, unless sooner revoked in writing and delivered. The undersigned further releases Wayfinder Family Services, its officers, agents, and employees from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of Wayfinder Family Services. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person or I (we) will institute any suite or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of Wayfinder Family Services (including but not limited to Camp Bloomfield) in which the person participates.
Current Medical Insurance is mandatory in order to participate in any recreation activity or event. Any medical costs incurred while participating in any Wayfinder Family Services’ Recreation Program (including Camp Bloomfield) shall be the responsibility of the participant’s parent or guardian. Medical costs include: physician visit, emergency room visit, prescription medication, and/or emergency transportation. It is also to be understood and agreed that any and all such medical, dental, hospital, or similar expenses incurred in the treatment of the participant will be borne solely by the parent or guardian. If a situation requires medical treatment, the parent or guardian will be contacted by a staff member and informed of the situation. Should a situation arise where the parent or guardian cannot be reached, the participant will be taken to the local emergency facility for treatment. I have read, understand, and received a copy of this document. * Required PARTICIPANT/PARENT/GUARDIAN MEDIATION AND ARBITRATION AGREEMENT
This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned camper and/or their legal guardian and Wayfinder Family Services and the California Yacht Club.
In the event of any unresolved dispute, claim or controversy by the camper and/or their legal guardian against Wayfinder Family Services, its directors, officers, employees or agents, the student and/or their legal guardian agrees to submit such unresolved dispute, claim or controversy, including but not limited to all claims for breach of contract and civil torts, to non-binding mediation before a neutral independent third-party mediator and, if that process does not result in full resolution of the dispute, to final and binding arbitration, including, but not limited to, claims for breach of contract and civil torts.
The arbitration shall be conducted by a single-arbitrator s elected either by mutual agreement of the camper and/or their legal guardian and the Wayfinder Family Services or, if they cannot agree, from an odd-numbered list of experienced arbitrators provided by the American Arbitration Association. Each party shall strike one arbitrator from the list alternately until one arbitrator remains.
The arbitrator shall have all powers conferred by law and a judgment may be entered on the award by a court of law having jurisdiction. The award and judgment shall be in writing and binding and final on both parties.
Each party shall have the right to conduct reasonable discovery, as determined by the arbitrator and as provided in
California Code of Civil Procedure Section 1283.5(a).
The parties agree to submit any unresolved dispute or unresolved controversy arising out of or relating to the terms of the Agreement to mediation, and if that process does not result in full resolution of the dispute to final and
binding arbitration by a single neutral arbitrator.
Wayfinder Family Services agrees to pay for 75% of the costs of the mediation and arbitration proceedings and the fees of the arbitrator. The remaining 25% of the costs and fees of the mediation and arbitration will be paid by the camper and/or t heir legal guardian. Recognizing that parties involved in any such dispute may have limited resources, the parties agree to endeavor in good faith to identify a mediator and an arbitrator whose fees and costs are reasonable and affordable in light of that fact.
This agreement shall continue during the period of service delivery and thereafter regarding any related disputes. This agreement may only be modified for the Wayfinder Family Services by a written agreement signed by the President of the Wayfinder Family Services.
The camper and/or their legal guardian understand that by signing this Agreement, he/she gives up his/her right to a civil trial and his/her right to a trial by jury.
If any of the provisions of this Agreement are found null, void, or inoperative, for any reason, the remaining provisions will remain in full force and effect.
Media Release COVID Information * Required I acknowledge that my participation (or my child’s) in Wayfinder Family Services program is at my own risk.
While participating in events held or sponsored by Wayfinder Family Services, consistent with CDC guidelines, participants are encouraged to practice hand hygiene, “social distancing” and wear face coverings to reduce the risks of exposure to COVID-19. Because COVID-19 is known to be contagious and is spread mainly from person-to-person contact, Wayfinder Family Services has put in place preventative measures to reduce the spread of COVID-19. However, Wayfinder Family Services cannot guarantee that its participants, volunteers, partners, or others in attendance will not encounter COVID-19.
Media Release * Required I have read and agree to the MEDIA RELEASE
Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the camper noted in this application for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality.
On occasion, specific campers are identified for profile stories used in grant applications and reports, publications, websites or social media sites. Permission is hereby given to WAYFINDER FAMILY SERVICES® to publish this camper’s story in grant applications and reports, publications, websites or social media sites, with related quotes, after verbal and/or written approval of that story has been granted by said person or by the undersigned on his/her behalf or individuality.
Name/Signature * Required
Type your full name to sign
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