2017 Camp Registration Form



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Registration
Your Name & Contact Info
Grouping Policy

Children are organized strictly by their birthdate into four groups: Clippers (7-8 yrs), Schooners (6-7 yrs), Sloops (5-6 yrs) and Prams (4-5 yrs). We cannot take requests for group placement. Final participant lists will be emailed out in June. There are no exceptions to this rule.

Child's Information
Parent's Information
Phone & Contact Information
Emergency Contact Information

In the event of an emergency when I may not be reached, the EYC Junior Activity head counselor or EYC General manager may contact the following individuals (in the order given) whom I authorize to take my child from The Eastern Yacht Club Camp and facility.

Medical Information
I authorize all medical care and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency. 

AUTHORIZATION: I hereby authorize any medical treatment deemed necessary in the event of any injury to my Child while participating in the EYC Jr. Activities Camp. I have appropriate insurance or, in its absence, I agree to pay all costs of medical services and medical transport as may be incurred on behalf of my Child.

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I hereby authorize any medical treatment deemed necessary in the event of any injury to my Child while participating in the EYC Jr. Activities Camp.

I have appropriate insurance or, in its absence, I agree to pay all costs of medical services and medical transport as may be incurred on behalf of my Child.

Health History
Authorized Person(s) to Pick Up Child

I additionally authorize the following individual to take my child from the Eastern Yacht Club Junior Activities program.

NOTE: If your child or children will be picked-up on a regular basis by someone other than yourself please list their name and contact information below.

NOTE: It is advised that you notify the camp at the beginning of the day when your child will be picked up by one of the authorized individuals.

Authorization to Administer Medication to a Camper

If Yes, please complete the remainder of this section below.

I hereby authorize the EYC Junior Activities Program to administer, to my child listed above the medication(s) listed above, in accordance with 105 CMR 430.160.

105 CMR 430.160(A)
Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist's initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use.

105 CMR 430.160(C)
Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian.

105 CMR 430.160(D)
When no longer needed, medications shall be returned to a parent of guardian whenever possible. If the medication cannot be returned, it shall be destroyed.

*Health Supervisor - A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications.

On-the-Water Activities Acknowledgement & Release Agreement

The undersigned acknowledges and understands the following (NOTE: where the program participant is a child under the age of 18, the undersigned must be a parent or other legal guardian):

1. The Eastern Yacht Club program participants, parents and legal guardians have been given the opportunity, at scheduled meetings and otherwise, to ask questions and discuss with EYC staff the safety and recreational aspects of EYC on-the-water programs and activities prior to their commencement.

2. The EYC has made reasonable and prudent efforts to safeguard the health and well-being of participants in EYC on-the-water programs and activities through safety policies and staff supervision of activities, among other measures. Such policies include, without limitation, (A) a strict policy regarding the required use of personal floatation devices by all program participants under the age of 16 during program activities; and (B) the administration of a swimming test appropriate to the activities of the program and its participants.

3. No safety measures, including those described above, can guarantee the safety of any participant in EYC on-the-water programs and activities. Accordingly, the undersigned hereby releases the EYC, its employees, volunteer staff, agents and members from, and waives any and all claims, losses or liabilities resulting from or related to, the above-named person's participation in on-the-water programs and activities of the EYC.

Immunization Forms

The Marblehead Board of Health requires that we have on file necessary information for your child on hand and in order for your child to attend Camp this summer. We must have a hard copy of you child's/children's medical history and immunizations forms (not unlike required to attend school) sent directly to Talbot Fall at 25 Willow Road, Marblehead, MA 01945. The deadline for this is May 1, 2017.

Registration Subtotal
* Denotes Required Field

Grandparents may register their grandchildren at any time.