S.T.O.M.P

Child First and Last Name

Child Age

Birth Date

Grade

Address

Parent/Guardian Name

Parent/Guardian phone number

Parent/Guardian email address

Emergency contact first, last name, and phone number.

T - Shirt Size

YS
YM
YL
XS
S
M
L
XL
XXL

Does your child have any allergies? If so, please provide that information below.

User Agreement

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Stomp the World during the S.T.O.M.P Spring Break Camp. In exchange for the acceptance of my child’s candidacy by  Stomp the World, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Stomp the World,  and all its representatives and volunteers from any and all liability for injuries to my child arising out of traveling to, participating in, or returning from all activities.

In case of injury to my child, I hereby waive all claims against  Stomp the World, including all staff members, volunteers, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities. 

User Agreement

Medical Release and Authorization

As Parent/Guardian of my child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for my child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Stomp the World, and its affiliates including Directors, Respresentativs and Volunteers, to provide the needed emergency treatment prior to my child’s admission to the medical facility.

Release authorized on the dates March 20 - 24, 2023

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of my child, in my absence.

CONFIRMATION

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Electronic Signature (First and Last Name)