Keiki Health Day Camp
April 19th, 2015; 9am-2pm
John A. Burns School of Medicine
651 Ilalo Street, Honolulu, HI, 96813
Have your child (K-5) come join us for a day of health-related activities
that include obstacle courses, arts & crafts, and games! Please note that a
snack and lunch are provided. Please see the back of this flyer for the
day’s schedule.
Spots are limited, so register today at:
http://tinyurl.com/healthykeikicamp
For more info: email [email protected]
TIME
9:00-9:15 AM
9:30-10:00 AM
GRADES K-1
ACTIVITY #1
ACTIVITY #2
12:15-1:00 PM
1:00-2:00PM
ACTIVITY #3
ACTIVITY #3
ACTIVITY #4
BATHROOM BREAK
ACTIVITY #3
11:30-11:45 AM
11:45-12:15 PM
ACTIVITY #2
BATHROOM BREAK
10:45-11:00 AM
11:00-11:30AM
GRADES 4-5
CHECK-IN BY 9:15AM
John A. Burns School of Medicine, Medical Education Building Next to
Kaka’Ako Makai Gateway Park - Cooke St. (See “STAR” on Map Below)
10:00-10:15 AM
10:15-10:45 AM
GRADES 2-3
ACTIVITY #4
ACTIVITY #1
BATHROOM BREAK
ACTIVITY #4
ACTIVITY #1
ACTIVITY #2
LUNCH
(Food will be provided)
FREE PLAY, CHECK-OUT
Medical Education Building, Next to Kaka’Ako Park - Cooke St.
(See “STAR” on Map Below)
ACTIVITY #1: HUMAN ANATOMY
ACTIVITY #2: DENTAL HYGIENE
ACTIVITY #3: HEALTHY SNACK
ACTIVITY #4: SUN SAFETY + FITNESS
DROP OFF & PICK UP
KEIKI HEALTH DAY CAMP REGISTRATION FORM – APRIL 19, 2015
(Please Print)
CHILD/YOUTH INFORMATION:
Child’s last name:
First name:
Gender:
q Male q Female
Grade completed:
School name:
Birth date: (MM/DD/YY)
/
/
Age:
FAMILY INFORMATION:
Mailing/Street address:
City:
Father/Guardian last name:
First name:
Mother/Guardian last name:
First name:
State:
ZIP Code:
Best phone number to be reached at:
(
)
Best phone number to be reached at:
(
)
EMERGENCY CONTACTS:
First person to contact:
Relationship:
Second person to contact:
Relationship:
Best phone number to be reached at:
(
)
Best phone number to be reached at:
(
Alternate phone:
Alternate phone:
)
PICK-UP AUTHORIZATION:
I authorize my child to be released to the following individuals:
*Please note that on the day of the health camp, individuals will need to show an ID to be able to sign-out your child
Name of Individual:
Relationship:
Name of Individual:
Relationship:
MEDICAL INFORMATION:
Physician to contact:
Phone number:
Please list any medical (such as allergies) or other limitations
that might hinder participants:
Choice of hospital:
Please list any special requirements or conditions:
RELEASE WAIVERS:
I authorize the John A. Burns School of Medicine (henceforth referred to as “JABSOM”) and the University of Hawai’i to use the name and
any video/photographs/audio taken of my participant at anytime or in any manner in connection with its advertising, publicity and public
relations programs. The JABSOM and University of Hawai’i may only use the video/photographs/audio. I will make no further claims.
Guardian’s printed name and signature
Date
MEDICAL CONSENT AUTHORIZATION:
If in the judgment of the JABSOM and University of Hawai’i staff, my child requires medical care, I authorize JABSOM and University of
Hawai’i to inform me or the authorized person listed above. The JABSOM and University of Hawai’i may take me in for medical treatment to
the physician, hospital or clinic, I or the authorized person designated. If the authorized person, the physician, or I can’t be promptly
reached, I authorize the JABSOM and University of Hawai’i to take my child to the nearest hospital or clinic for such medical treatment. I
am covered by:
[NOTE: For the purposes of this Agreement, the term “I” refers to both Parent/Legal Guardian and Student.]
I, the undersigned, consent to and authorize any medical professional and others working under their supervision to treat me for any injury
th
or illness arising from or related to my participation in Keiki Health Day Camp on April 19 , 2015. I further agree to pay any and all medical
expenses, costs and other charges and to release and discharge and hold harmless the University of Hawai`i, JABSOM and staff, and the
State of Hawai`i, its officers, employees, agents, and assigns from and against any liability or any claims or demands arising from or
connected with such medical treatment or care.
Guardian’s printed name and signature
Date
Name of Medical Insurer
Card/Policy Number
ASSUMPTION OF RISK, RELEASE, AND INDEMNITY AGREEMENT:
[NOTE: For the purposes of this Agreement, the term “I” refers to both Parent/Legal Guardian and Student.]
I understand that _______________________________ will be participating in KEIKI HEALTH DAY CAMP
(Print Student’s name)
(Activity)
on April 19, 2015. I understand that there are minimal inherent dangers and risks involved with participation in this activity, which include,
but are not limited to: cuts, scrapes, and possible exposure to bodily fluids. I agree to strictly follow all safety procedures and guidelines. I
am fully aware that there are inherent risks of injury that include, but are not limited to, illness, personal injury, or death.
I understand that the University of Hawai`i does not provide health insurance or otherwise indemnify individuals with respect to injuries or
other liabilities arising out of participation in the field trip/activity.
In consideration of Student being permitted to participate in the Activity:
I agree, for myself, my heirs, personal representatives and assigns, to hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO
SUE the University of Hawai`i, its Board of Regents, officers, employees and agents from any and all claims, including, but not limited to,
claims for property damage, personal injury, illness, or death, arising from my involvement or participation in the activity.
I also agree to DEFEND, INDEMNIFY AND HOLD HARMLESS the University of Hawai`i, its Board of Regents, officers, agents and
employees from and against any and all claims, demands, actions or causes of action, on account of any loss, including damage to
personal property, or personal injury or death, which arise out of my involvement or participation in the activity.
I also agree that this Agreement shall be construed in accordance with the laws of the State of Hawai`i. I further agree that if any portion is
held invalid, the remainder will continue in full legal force and effect. I have read this Assumption of Risk, Release and Indemnity
Agreement and I understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing this Agreement
freely and voluntarily.
Guardian’s printed name and signature
Date