GEMS Parent Questionnaire

Course (required)
GEMS: Shining BrightGEMS: Digging DeeperGEMS: Rock OnGEMS: Be GenuineGEMS: Crowning Jewel

Course Start Date

Daughters Name:

Preferred Name:

Parent/Guardian Name (required)

Parent/Guardian Email (required)

Parent/Guardian Mobile Phone

Mailing Address

City, State, Zipcode

Birth date

Are you a previous GEMS camper?

YesNo

If yes, skip down to Refund Policy and Health History form. If no, please answer the next few questions

Please list your daughter’s camp learning objectives

How did you hear about GEMS Camp?

Describe your daughter's previous experiences away from home.

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.

I herby agree to the refund policy
Agree

Health History Form

Height

Weight

Doctor's Name

Doctor's Number

Please complete the following regarding medical and health history:

Is your daughter currently under treatment for any illness, injury, or medical condition?
YesNo

If yes, please describe

Is your daughter allergic to anything? If so, list allergies.

Does your daughter have any dietary restrictions? If so, list restrictions.

Has your daughter begun menstruating?
YesNo

Is your daughter currently taking any medications (prescription, over-the-counter, or vitamins)?

YesNo

If yes, please list

Permission to Administer Over-The-Counter Medications:

I give the camp director and staff permission to administer over-the-counter medications to my daughter.

(Initial)

List any over-the-counter medications you do NOT give camp director and staff permission to administer.

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.

Please list anything else we should be aware of regarding your daughter’s physical and emotional health current and past.

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

In the event my daughter needs emergency care due to illness or accident while participating in GEMS Camp activities, I hereby give permission to qualified emergency care personnel, to secure treatment and take whatever medical action(s) to treat my daughter.

(Initial)

Medical Costs

I hereby assume responsibility for all medical expenses that my daughter may incur while participating on this trip.

(Initial)

Health Insurance Information:

Carrier

Policy Numbers

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 Camps (with exception of GEMS: Shining Bright, 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.

I agree that all the above information is true and complete. I agree to the terms of Participation Agreement above.
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.

By checking "Agree" I hereby understand and agree to the above Photo Release:
Agree