WAVE Onsite Programs

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Complete a form for each participant.

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Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Participant Name

First NameLast Name
Participant's Preferred Name (if applicable)
Birth Date

MonthDayYear
Date
Gender
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Additional Emergency Contact

First NameLast Name
Additional Emergency Contact Phone
Format: (000) 000-0000.
What have we forgotten to ask? Please provide any additional information about the participant that you think important or that may affect their ability to fully participate in the camp program.

I agree that WAVE Foundation and Newport Aquarium has my permission to use the participant's photograph for educational and public relations purposes related to Newport Aquarium and WAVE Foundation.
Permission to Treat Authorization I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related tranportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

If the person named herein is a minor, it is my intention that representatives of the WAVE be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to WAVE representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in WAVE activities; and if the person named herein is a minor, to provide information to the WAVE representatives to keep me informed of my child's health situation.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by WAVE staff to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of WAVE.
Behavior Contract To ensure safety, inappropriate behavior will not be tolerated. Examples of inappropriate behaviors include, but are not limited to: mistreating animals, name calling, arguing with staff, foul language, bullying, fighting, stealing, deliberate property damage, and disobeying safety regulations. We promote conscious discipline practices. Depending on the severity of the behavior, WAVE staff may work through the following consequences: verbal warning, individual conversation with supervisor, time out from activities, call to guardian, suspension and removal from program.

By completing this form, I agree that my camper and I have read and understand the WAVE behavior policy.
Liability Release My camper has my permission to attend and participate in WAVE programs. I recognize and acknowledge that participation is voluntary and does involve risk of accident or personal injury. Accordingly, in consideration for allowing the participant to participate, I hereby release WAVE Foundation, Newport Aquarium, staff and representatives, sponsors and any other participants, from any and all claims, causes of action, injuries, damages and liabilities of any nature whatsoever arising out of, or relation to, participation in the program.
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.
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