AHOY 102014 Crew Kids Ahoy! Registration Form Please note that you must complete a Registration Form and a Hold Harmless Agreement for each child attending the event(s). Instructions: Complete each form and save to your hard drive. E-mail a copy of the completed Registration Form(s) to Creative Events at [email protected]. When you receive a confirmation e-mail from Creative Events, print out and sign the Registration Form(s) and Hold Harmless Agreement(s). Photocopy your Vanguard ID card, and, if applicable, the Vanguard ID card(s) of the person(s) responsible for picking up your child(ren). Within three business days of receiving confirmation, mail your completed and signed paperwork, the photocopied ID card(s), and your payment to: Creative Events ATTN: Margaret Van Gilder 1033 Harmony Hill Road Downingtown, PA 19335 Tuition is $40 per event, per child, payable by check made out to Creative Events. If you prefer to pay with cash, please contact Creative Events at 610-209-9410 or [email protected] to make arrangements. 1. Crew member Crew ID # Name 2. Dates attending (See CrewNet article for dates and activity information.) Please fill in the boxes Please fill in the boxes with the with thedates datesattending. attending. > 3. Child information Name Age Grade Birth date (mm/dd/yyyy) School district attended 1 of 4 AHOY 102014 4. Parent or guardian information Relationship Name Home phone Work/cell phone Street address City, state, zip E-mail address (confirmation will be sent to this address) 5. Emergency contact information Name Relationship Home phone Work/cell phone Street address City, state, zip 6. Child’s medical information Doctor Name Phone number Street address City, state, zip Dentist Name Phone number Street address City, state, zip 2 of 4 AHOY 102014 Health information Known allergies (including food allergies) and medical conditions Medications and dosages Insurance company Name of provider Member identification number Member name Other notes 7. Person(s) authorized to pick up child (You must provide copies of their Vanguard ID) Name Relationship Name Relationship 8. Signature of parent or guardian I understand that in the event my child requires medical treatment while participating in Crew Kids Ahoy! activities, reasonable efforts will be made to contact me or the emergency contact listed above. If either I or the emergency contact is unavailable, I authorize The Vanguard Group, Inc. employees and Crew Kids Ahoy! service providers to have my child transported to the nearest medical facility for treatment. I give consent to the medical facility, licensed physician, or other licensed medical professional to perform or administer medical care to my child as deemed appropriate. I authorize disclosure of the above medical and insurance information to the medical facility, licensed physician, or other licensed medical professional in the event my child should require medical care. Parent or guardian’s signature Parent or guardian must sign in the box. Date (mm/dd/yyyy) > 3 of 4 AHOY 102014 Hold Harmless Agreement • I, , the parent/guardian of , a participating minor child (“Child”), understand that this trip/activity has been organized by The Vanguard Group, Inc. (“Vanguard”) in order to offer Vanguard crew members the benefits of group travel and/or activities. On behalf of myself and my Child and in consideration of my Child’s participation in this trip/activity, I assume full and complete responsibility for my selection of the trip/activity and for the participation of myself and/or my Child in such trip/activity. • I am aware that this program is offered to Vanguard crew members only with school-age children, stepchildren, and domestic partners’ children ages five through thirteen. • I understand that the activities that I and/or my Child will participate in may be inherently dangerous and may cause injuries, including bodily injury, damage to personal property, and/or death. On behalf of myself and/or my Child, our heirs, executors, and administrators, I do hereby release and hold harmless Vanguard, its affiliates and subsidiaries and their respective present and former officers, directors, trustees, employees, shareholders, and agents and all group travel/activity service providers from any and all liability, specifically including, but not limited to, claims for physical injury, and any other direct, indirect or consequential loss, including loss or damage of personal property relating to such trip or activity. • Further, I hereby grant to Vanguard the right and full permission to use any photographs or videotaped or otherwise recorded images of me and/or my Child and/or our voices taken by or on behalf of Vanguard for this event involving me or my Child for the sole purpose of promoting Crew Kids Ahoy! Printed name of child Printed name of parent/guardian Street address City, state, zip Home phone Work/cell phone Parent or guardian’s signature Parent or guardian must sign in the box. Date (mm/dd/yyyy) > Printed name of crew member, if different from parent/guardian Crew ID # 4 of 4
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