SPACE FLIGHT ADVENTURE CAMP
VIRGINIA SPACE FLIGHT ACADEMY

MEDICAL / PHOTO RELEASE / REFUND POLICY

 

I am the parent or legal guardian of______________________________(please print full name) referred to later as "child"). I am familiar with the activities of the Virginia Space Flight Academy (referred to later as "Academy") and I hereby authorize my child's participation in the Academy on the camp dates of:__________________,2010.  I know of no physical, mental, emotional, or behavioral problems that will affect my child to participate safely.

 

IN CONSIDERATION FOR BEING ACCEPTED AND ALLOWED TO PARTICIPATE IN THE ACTIVITIES OF THIS ACADEMY MY CHILD AND I PERSONALLY ASSUME RESPONSIBILITY FOR MY ACTIONS AND THOSE OF MY CHILD.  WE AGREE TO ABIDE BY THE RULES OF THE ACADEMY AND TO RELEASE, HOLD HARMLESS, AND INDEMNIFY THE US. GOVERNMENT, THE VIRGINIA COMMERCIAL SPACE FLIGHT AUTHORITY, THE VIRGINIA EASTERN SHORE REGIONAL PARTNERSHIP, THE VIRGIINIA SPACE FLIGHT ACADEMY BOARD OF DIRECTORS, THEIR EMPLOYEES, AGENTS, CONTRACTORS, OFFICERS AND TRUSTEES FROM LOSS, INJURY, ATTORNEY FEES, AND/OR OTHER DAMAGE. I GIVE THE ACADEMY PERMISSION TO USE MY CHILD’S PHOTOGRAPHS OR VIDEOS FOR NEWS RELEASES, ADVERTISING, BROCHURES, FLYERS OR ANY OTHER MEDIA TO PROMOTE OR ADVERTISE FUTURE CAMPS.

 

CANCELLATION / REFUND POLICY: VSFA incurs certain costs prior to camp such as room and meal guarantees, therefore, in the event of a cancellation 2 weeks prior to camp date, a refund of $495.00 will be applicable. In the event of a cancellation less than 2 weeks prior to camp date, there will be no refund unless there is a medical statement signed by camper's physician in which case the $495.00 refund will apply.

 

I consent to the examination and treatment of my child by a physician and/or hospital emergency room; I also understand that neither the Virginia Commercial Space Flight Authority, the Eastern Shore Regional Partnership, nor anyone connected with them will assume responsibility for payment of any medical, dental, or other expenses incurred as a result of sickness and/or injury.

 

PLEASE NOTE;  OUR STAFF CANNOT ADMINISTER ANY MEDICATIONS, PRESCRIPTION OR NON-PRESCRIPTION, OR PROVIDE OTHER CARE.  This agreement shall be governed by Virginia law; any claim hereunder must be brought in Norfolk, Virginia.  This form represents the entire agreement of the parties on the subject.

 

My child takes the following medication:______________________________________________________________.

(Optional) My child's social security number is:_________________________________________________________.

(Optional) My child's date of birth is:_________________________________________________________________.

 

______________________________________________________________________________________
Signature of parent or Legal Guardian                              Printed Name                                        Date

 

______________________________________________________________________________________

Street                                   City                                       State                      Zip Code        (Tel. number(s)

 

______________________________________________________________________________________

Primary Emergency Contact Name                                  Relation                                      (Tel. number(s)

 

______________________________________________________________________________________

Secondary Emergency Contact Name                             Relation                                      (Tel. number(s)

 

______________________________________________________________________________________

Medical Insurance Company                                Subscriber's Name                        Policy/Group/ID Numbers

 

MANDATORY MEDICAL STATEMENT:  I have examined______________________________________

on________________.  He/She is in good health and is physically and mentally able to participate in academic camps such as the Academy.  Participation will not pose a threat to him/her or to those around him/her. He/She does not have any iniury or illness that will prohibit this activity.  ANY SPECIAL COMMENTS, KNOWN FOOD, DRUG, OR OTHER ALLERGIES ARE NOTED BY A SEPERATE SIGNED SHEET ATATCHED TO THIS FORM.

  

______________________________________________________________________________________

Physician's / Parent’s Signature                                        Printed Name                                       Phone Number(s)

 

Please attach a copy of your child's insurance information.