Loading...

Baroody Camps, Inc.

343 Gundry Drive

Falls Church, VA 22046

Welcome to Baroody Camps!

We are looking forward to our upcoming camps, and can't wait to have your child(ren) join us.

Please fill out the following information prior to your camper(s) joining us at camp.

PLEASE NOTE:

You must fill out one (1) form per camper, as per the state requirements set by the Department of Social Services.

Campers at all locations, you must submit the Virginia Health Form for all Rising Kindergarteners (via email or first day of camp).

Immunization Records must be submitted for Grades 1-9.

*Reminder: please email or bring in the original or a copy of your camper(s) proof of identity. A list of acceptable forms are posted in our Parent Handbook.

For more information, please see our Parent Handbook posted on our website www.baroodycamps.com

 

Questions? E-mail us at info@baroodycamps.com

 

 

Please select who will be participating in camp...
Minor
Continue
First Camper's Name

First Name*

Last Name*

Phone*
First Camper's Age Acknowledgment*
First Camper's Date of Birth*
I certify that I am 18 years of age or older
First Camper's Health Information

Please enter the date of your child's last Tetanus Booster Shot *
Does your child have any known medical conditions and/or allergies?*
Yes
No

**If your child has an allergy, asthma or other special consideration and/or requires medication, you must complete our separate allergy/asthma waiver.


Enter the Name of your Family or Child's Physician *

Provide a Contact Number for your Family or Child's Physician *

Provide the Address of your Family or Child's Physician *
First Camper's Signature*
Camper's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent/Guardian Information

Parent/Guardian Name *

Parent/Guardian Phone Number *

Parent/Guardian Address (street, city, state, zip) *

Parent/Guardian Name

Parent/Guardian Phone Number

Parent/Guardian Address (street, city, state, zip)
**The Department of Social Services requires information for two designated people to call in an emergency if a parent cannot be reached**
1st Emergency Contact (please list someone in state who is not a parent/guardian).

Name *

Phone Number *

Address (street, city, state, zip) *
2nd Emergency Contact (please list someone in state who is not a parent/guardian)

Name *

Phone Number *

Address (street, city, state, zip) *
Authorized Pick-Up

Please list the name and contact phone number for person(s) - other than the primary parent or guardian - authorized to pick up your camper: *
Photo Release
Baroody Camp's, Inc. requests permission to use the images of campers collected during camp for newsletters, marketing and camp promotion purposes. We plan to use them to promote our future camp and class offerings. By agreeing to allow Baroody Camps to use the images, we recognize that there is no compensation associated with the usage of camper images.*
I give permission to Baroody Camps to use the images of my child to market their programs.
I do NOT give permission to my child's image to be used by Baroody Camps for marketing purposes.
Transportation
I give permission for my child to be transported in a motor vehicle driven by a Baroody Camps employee on Swimming Fridays (Grace Episcopal location only) or registered camp Field Trips. I understand that the Baroody Camps staff driving the vehicle has incurred no moving violations in the past 5 years. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the direction provided by the driver and/or other employees.*
No
Yes

I have read, understand, and discussed with my child that:

  • The will be traveling in a motor vehicle driven by an adult and they are to wear their safety belt while traveling;
  • They are expected to respect each other, the vehicle(s) they ride in, and the personnel they travel with during the trip;
  • Riding in a motor vehicle may result in personal injuries or death from wrecks, collisions or acts by riders, other drivers or objects; and
  • They are to remain in their seats and not be disruptive to the driver of the vehicle
By electronically signing this waiver, I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal i injury or permanent loss. I recognize the risk that my child may suffer an emotional or physical injury or disability and release Baroody Camps, Inc, its President, and it employees from all liability associated with such risks. I hereby attest and verify that I have been advised of any potential risks involved in this activity, and that I assume any expenses that may be incurred in the event of an accident, illness, or other incapacity, regardless of whether I have authorized such expenses.

Swimming
In order for your child to participate in any swimming or pool activities with Baroody Camps, we must have your permission. Please mark your preference for your child's involvement in any pool or swimming activities:*
I give permission for my child to participate in swimming and pool activities at Chinquapin (Grace Episcopal location) and LHP while attending Baroody Camps between June 19th and August 18th.
I DO NOT give permission for my child to participate in swimming and pool activities while attending Baroody Camps between June 19th and August 18th.
This does not apply to my child
My child's swimming ability is designated as: (please check one)*
Beginner
Intermediate
Advanced
Swim Team
Lifeguard

Please note: Baroody Camps lifeguard certified counselors will be present at Little Hunting Park (LHP). All Baroody Camps counselors (at all locations) are CPR and First Aid certified.

By electronically signing this waiver, I recognize that I have answered my child's swimming ability to the best of my knowledge and that I give permission to Baroody Camps counselors to chaperone my child. In the event of injury or death, I release Chinquapin, Little Hunting Park, its pool operators, its lifeguards, its staff and volunteers as well as the Director/President of Baroody Camps, Inc., of all its staff and volunteers from any and all liability and responsibility in connection with any occurrence during a Baroody Camps, Inc. camp session. 

Non-prescription Over-the-Counter Skin Products

This form must be completed by the parent/guardian to authorize the use of:

  • Sunscreen
  • Insect repellent

Baroody Camps has my permission to apply the non-prescription over-the-counter (OTC) skin SPRAY product listed below to my child. Please note: Baroody Camps does not allow its counselors to apply sunscreen or insect repellent unless spray is provided.*
No
Yes

All OTC products must:

  • Be in the original container and, if provided by the parent, labeled with the child's name
  • Be used according to manufacturer's recommendation and instructions for application
  • Not be used beyond the expiration date of the product
Sunscreen:
  • Must have a minimum SPF of 15
  • Shall be inaccessible to children under 5 years of age
  • Children 9 years and older may self administer sunscreen, if supervised
Insect Repellent:
  • Shall be kept inaccessible to children


Product Name

Known adverse reactions (if any)
Illness
I acknowledge that Baroody Camps will notify the parent/guardian of a child that becomes ill and that the parent will arrange to have the child picked up as soon as possible if so requested by the center *
Yes
I acknowledge that the parent/guardian will inform Baroody Camps within 24 hours or the next business day after their child or any member of the immediate household has developed any reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. *
Yes
Medical Release and Liability

As the Parent and Legal Guardian of the specified camper, I request that in my absence the above named minor be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and staff duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of the examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named minor.

Acknowledgement of Parish and/or School role in the camp:

The above-named minor is a participant in Baroody Camps, Inc. and we hereby acknowledge that this program may involve a variety of activities which may be both physical and mental in nature. These activities are designed to be within the limits of a person who is reasonably good health. The level of participation in all programs and activities is at all times completely up to my child. By electronically signing this waiver, I recognize the risk that my child may suffer an emotional or physical injury or disability and release Baroody Camps, Inc, its President, and it employees from all liability associated with such risks. I give my child permission to participate in the camps indicated above. I have no knowledge of any physical impairment that would affect this camper from participating in the camps' Programs. I agree that in case of accident while participating in these camps, I release the camp, the camp director, and other educational facilities that may be used for camp from any liability.

Liability coverage:

The Parish and/or School is not furnishing and is not responsible for and assumes no liability in connection with participation in this camp. The Parish and/or School is not furnishing and is not responsible for and assumes no liability of guarantee or assurance of safety of participant and/or the elimination of all risks from the environment. The Parish and/or School is not furnishing and is not responsible for and assumes no liability for the safety of personal property during participation in the program. The Parish and/or School is not furnishing and is not responsible for and assumes no liability for monitoring and/or control of all the daily personal decisions choices and activities of the individual participants. The Parish and/or School is not furnishing and is not responsible for and assumes no liability for assumption of responsibility for the actions of persons who are not volunteers or employees of the Parish and/or School or otherwise engaged by the Parish and/or School, for events that are not part of the program, or that are beyond the control of the Parish and/or the school and its subcontractors. I voluntarily and without reservation and on behalf of myself, my child who is signed up for this program, my heirs, and my estate, hereby indemnify, defend and hold harmless the Parish and/or School, to include but not limited to Baroody Camps, Inc. and all associated employees, the Diocese of Arlington, the most Reverend Paul S. Loverde and his successors in office, their officers and employees from any and all liability, loss damages, costs or expenses which are sustained, incurred, or required arising out of mine or my above noted child's actions in the course of the above program and activities.

Use of Vehicles:

I further acknowledge, with regard to any personal vehicle driven by me or which I am a passenger in, that in the event of an accident, there is no coverage afforded to me through Baroody Camps, Inc. or the Diocesan Master Insurance Program for liability or physical damage sustained to any vehicle involved or liability incurred by me while operating my vehicle. I acknowledge that if I choose to park at any Baroody Camps or Diocesan facility, I do so at my own risk.

Reimbursement of Medical Expenses:

I recognize and acknowledge there is no volunteer accident coverage nor is there any medical payments coverage available to me or my participating child in order to compensate me for expenses I incur from deductibles, co-payments, prescription drugs, or medical services not covered through my own health insurance provider(s) for any injury my child sustains as a result of participation in the above mentioned camps. I agree that any medical coverage(s) I have will be primary and under no circumstances will I seek any contribution from Baroody Camps, Inc, it employees, its president, their insurer, the Diocese of Arlington, or their insurer, for any medical expenses.

Informed Consent to Medical Treatment:

In the event of an injury, I hereby give Baroody Camps, Inc., its President, its employees full authority to take whatever action they feel is warranted under the circumstances regarding my child's health and safety, if I am not present to give informed consent including but not limited to the application of emergency medical procedures, the admittance to a hospital or the care of a medical professional at my expense.

Safety - Catholic School Locations ONLY:

Further, I will hold myself accountable for my child(ren)'s agreement to follow all procedures and safety precautions set forth by Baroody Camps, Inc. in addition to ensuring the protection of minors from sexual misconduct and/or child abuse in order to conform with the requirements adopted by the United States Conference of Catholic Bishops and Catholic Diocese of Arlington Policy on the Protection of Children/Young People and Prevention of Sexual Misconduct and/or Child Abuse.

Safety - ALL Locations:

Further, I will hold myself accountable for my child(ren)'s agreement to follow all procedures and safety precautions set forth by Baroody Camps, Inc.

I freely execute this Acknowledgement with full knowledge of its content.


Furthermore, by signing this waiver, I certify that I have read and agree with all content in the Parent Handbook.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Health Information

Please enter the date of your child's last Tetanus Booster Shot *
Does your child have any known medical conditions and/or allergies?*
Yes
No

**If your child has an allergy, asthma or other special consideration and/or requires medication, you must complete our separate allergy/asthma waiver.


Enter the Name of your Family or Child's Physician *

Provide a Contact Number for your Family or Child's Physician *

Provide the Address of your Family or Child's Physician *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!