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GEMS Parent Questionnaire


    Course Start Date




    Parent/Guardian Name (required)










    Meals: Is your daughter allergic to any foods? If so, list allergies.



    YesNo

    Refund Policy

    In the event of student course cancellation, course payment will not be refunded. Monies paid
    will be applied to a future scheduled course date. Cancellations made within 30 days of course may be subject to a 25% reschedule fee. Mountain Shepherd, in review of certain situations, reserves the right to refund full course payment on a per case basis.

    Payment Policy

    Receipt of full course payment by Mountain Shepherd guarantees and reserves student’s placement.
    All required forms must be completed and signed by student and received by Mountain Shepherd prior
    to student’s arrival at training area. Mountain Shepherd reserves the right to consider special
    exceptions to this payment policy on an individual student basis.


    Agree

    Health History Form





    Please complete the following regarding medical and health history:


    YesNo



    Permission to Administer Over-The-Counter Medications:


    (Initial)


    Medical Policies and Procedures:

    All medications, both prescription and over-the-counter, are collected from campers and kept under lock. Prescription medications must come in original container with original directions. Camp director or staff will administer prescription medications as directed.


    Camp director or staff will call home for the following situations:

    • Minor cold, illness, or injury is persistent or does not improve with rest.
    • Camper requires attention outside camp staff’s purview of care.
    • Camper requires outside medical attention.
    • Camper begins menstruating for first time.

    Authorization for Emergency Care



    (Initial)

    Medical Costs



    (Initial)

    Health Insurance Information:



    Participation Agreement - Release and Assumption of Risk

    In consideration of the services of Mountain Shepherd LP, doing business as GEMS Camp, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “MS”), I hereby agree to release, indemnify, and discharge MS, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

    1. I acknowledge that hiking, camping, backpacking, kayaking, tubing, zip lining entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to my daughter, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity.
      The risks include, among other things: Slipping and falling; falling objects; water hazards; exhaustion; exposure to temperature and weather extremes which could cause hypothermia, hyperthermia, heat exhaustion, sunburn, dehydration; and exposure to potentially dangerous wild animals, insect bites, and hazardous plant life; equipment failure; and improper lifting or carrying.
      Furthermore, MS employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant’s fitness or abilities. They might misjudge the weather or other environmental conditions. They may give incomplete warnings or instructions, and the equipment being used might malfunction.
    2. I understand that during GEMS Camp 2, 3 and 4, MS will provide transportation to and from activities. I release, indemnify and hold harmless MS for any bodily injury to my daughter while being transported by vehicle by a MS Director, staff member or designated driver.
    3. I expressly agree and promise to accept and assume all of the risks existing in this activity. My daughter’s participation in this activity is purely voluntary, and I elect for her to participate in spite of the risks.
    4. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless MS from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of MS’s equipment or facilities, including any such claims which allege negligent acts or omissions of MS.
    5. Should MS or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.
    6. I certify that I have adequate insurance to cover any injury or damage my daughter may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition my daughter may have.
    7. I agree to pay for all damages to the facilities of Mountain Shepherd caused by my daughter’s negligent, reckless or willful actions.
    8. In the event that I file a lawsuit against MS, I agree to do so solely in the state of Virginia, and I further agree that the substantive law of Virginia shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining document shall remain in full force and effect.

    By checking "Agree" below and by submitting this form, I acknowledge that if anyone is hurt or property is damaged during my daughter’s participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MS on the basis of any claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.


    Agree

    Optional: Photo Release

    I grant to Mountain Shepherd, its representatives and employees the right to take photographs of my daughter in connection with her attendance in GEMS Camp.

    I authorize Mountain Shepherd, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

    I agree that Mountain Shepherd may use such photographs of my daughter with or without her first name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.


    Agree