2021 Camp Forms Camper Information
Please Select Which Camp You Are Registering For | Select One
Gender Male Female Choose Not To Disclose Parent | Guardian Information Health Information Food & Drug Allergies If Yes to Above, Please Explain What Happens
Are You Allergic to The Following
If Other Is Checked, Please List Special Dietary Needs Does Camper Have Any Known Physical Limitations or Abnormalities? Has Camper Had Chicken Pox Yes No Can Your Camper Swim Yes No Has Camper Had Lice in Last Six Months Yes No If Doctor Advises, Can Camper Take Tetanus Immunization Yes No
Is Camper currently taking any medications?
If yes, please complete the following information for each Medication. Any Special Medical Instructions? All Medicine needs to be labeled and given to the leader, the leader will give the medicine as directed.
Medical History - Please Select All That Apply | If None Apply Select N/A
PARTICIPANT AGREEMENT, RELEASE AND ASSUMPTION OF RISK 2021
The purpose of this agreement is to exempt, waive, release, and relieve the “Releasees” identified below from any and all liability, claims, losses, costs or damages, including, but not limited to, personal injury, property damage or wrongful death associated with the Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp and Young Women's Empowerment Journey Camp.
The Releasees include:
1. Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp, Young Women's Empowerment Journey Camp, owners Jay, and Terry Zipperman, individually, together with all directors, volunteers, participants, employees, representatives, agents, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as the “Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp, and Young Women's Empowerment Journey Camp.”). 2. Robert Lipman and Tri-Mountain Retreat, 1163 Hard Slate Road Elliay, Ga 30536.
I acknowledge, agree and represent that I understand that the nature of all wilderness recreational activities entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the program. These risks include (but are not limited to) camping, hiking, repelling, archery, the hazards of walking on uneven terrain, slips and falls, the forces of nature (including lightning and rapid weather changes), hypothermia, the risks of exposure to insect bites, the risks of snake bites, my own physical condition and the physical exertion associated with all the activities. These risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others participating in the activities, the conditions in which the activities take place, or the negligence of the “Releases” named above. I fully accept and assume all such risks and responsibility for any and all losses, costs, expenses, and damages I incur as a result of my participation in the Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp and Young Women's Empowerment Journey Camp.
Release for Indigenous Ceremonies
During the time in camp, campers will be invited to participate in indigenous based ceremonies which may require physical exertion. These activities may include but are not limited to, sleeping outdoors without a tent, ceremonial dancing or purification lodges. The campers are not required to participate and our staff carefully monitors the health and well being of each child.
I HEREBY RELEASE, WAIVE, RELINQUISH, DISCHARGE AND COVENANT NOT TO SUE THE RELEASEES FROM ALL LIABILITIES, CAUSES OF ACTION, CLAIMS, DEMANDS, LOSSES, EXPENSES, OR DAMAGES OF ANY KIND DIRECTLY OR INDIRECTLY CAUSED OR ALLEDGED TO BE CAUSED IN WHOLE OR IN PART BY THE ACTIONS OF THE RELEASEES OR THIRD PARTIES, INCLUDING NEGLIGENT RESCUE OPERATIONS, RELATED DIRECTLY OR INDIRECTLY TO THE MOUNTAIN WISDOM, INC., YOUNG MEN'S ULTIMATE ADVENTURE CAMP, YOUNG WOMEN'S EMPOWERMENT JOURNEY CAMP (COLLECTIVELY THE “RELEASED CLAIMS”); AND I FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEYS FEES, LIABILITIES, CAUSES OF ACTION, CLAIMS, DEMANDS, LOSSES, EXPENSES, OR DAMAGES OF ANY KIND FROM ANY RELEASED CLAIMS ASSERTED AGAINST RELEASEES BY OR THROUGH ME OR BY ANYONE ACTING IN CONJUNCTION OR IN CONCERT WITH ME.
In case of emergency, I hereby give permission to the physician, paramedic or medical staff selected by the staff of the Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp and Young Women's Empowerment Journey Camp to administer treatment as deemed necessary for the below Camper.
I do support and agree to abide by all camp regulations and policies. If I am being defiant, disruptive or exhibiting behavior that could be harmful to myself, other campers or staff, the staff will call legal authorities or parents to pick up camper immediately. I also understand that due to the nature of the summer camp budget that if the camper is required for any reason to leave the camp, there will be no refunds given.
Mature Audience Conversations.
Though it is not the intention of Mountain Wisdom or the Young Men and Women Camps to provide sex education, campers may bring up the conversation. We at Mountain Wisdom encourage the teens to show respect for themselves and their parents. From this perspective, we support the teens in following the guidelines created by their parents from a place of respect and honor.
I understand campers may be photographed for use by news media, publications, advertising or promotional materials, and we consent for Mountain Wisdom, Inc., Young Men’s Ultimate Adventure Camp, and Young Women's Empowerment Journey Camp to use all such photographs of the below Camper so made.
Mountain Wisdom, Inc. is a non-profit organization that offers outdoor experiences for children. While the participants may experience therapeutic benefits from the camps, we are not, by intention, therapeutic. Mountain Wisdom, Inc. is committed to being professional in regards to confidentiality though we are not held to therapeutic standards. Our professional standard for confidentiality is, as follows:
Everything that happens during our camps is to be held confidential. Participants may discuss what happens to them personally and insights or learning they received, but may not share specific information about the activities or any information about other participants. This confidentiality is in effect unless you or the participant is in danger or in any way not safe. This includes danger to yourself or someone else. It also includes anything that involves physical, emotional or other abuse or mistreatment. In these cases, the proper authorities will be immediately notified.
I have had sufficient opportunity to read this entire document. I have read and understood it, and I agree to be bound by its terms.
I am (we are) in favor of the Camper attending Young Men’s Ultimate Adventure Camp and Young Women's Empowerment Journey Camp and participating in all activities unless I (we) specify otherwise in writing. I (we) agree to all terms and conditions contained within this document both for ourselves and on behalf of the Camper. I (we) hereby expressly represent and warrant that we are the legal guardians of the Camper.
I (we) further agree to indemnify and hold Releasees harmless from any and all claims which are brought by or on behalf of the Camper, and which are in any way connected with the Camper. Mountain Wisdom Inc. Covid-19 Safety Plan and Agreement
The novel coronavirus, Covid-19, is a worldwide pandemic. Covid-19 is extremely contagious and is believed to spread mainly from person-to-person contact. It is believed that an asymptomatic individual can be infected and transmit Covid-19 without their knowledge.
Mountain Wisdom Inc. Covid-19 Safety Plan consists of, but is not limited to the following:
Covid-19 Pre-Screening Questionnaire for all participants including campers, parents and camp staff.
Release of Liability form
Covid-19 Safety Plan and Agreement
We are encouraging all staff to be vaccinated.
All campers and staff will provide proof of a negative Covid-19 test result.
Campers will sleep one per tent, except for siblings or campers that have quarantined together.
On camp site at registration: We will test each participant by taking temperature with Infrared No-Touch Forehead Thermometer. Anyone with a higher temperature than 100.4’ F, will be sent home and not allowed to participate. We will also inspect for Covid-19 related symptoms.
All participants will be escorted immediately to wash and sanitize hands and take part in training and demonstrations on behavior and precautions participants should abide by to prevent the spread of Covid-19.
All participants that do not have a mask will be given one and will carry mask with them at all times to use in the moments they find themselves in proximity with others.
Training will include:
Effective hand washing and sanitizing, (we have 80% alcohol hand sanitizer).
How to practice physical distancing in various settings, (we have 5’ foam noodles that when held out will help to designate a safe distance). We also have multiple 18”x24” signs that will also demonstrate these precautions.
Proper cough/sneeze techniques.
Regular cleaning/disinfecting of surfaces in food prep areas, bathrooms, activities and other areas.
No sharing of personal supplies, utensils, water bottles, food, hairbrushes, make-up.
I have read over this agreement carefully and completely and support and agree to abide by the Mountain Wisdom Covid-19 Safety Plan, guidelines and protocol. If I am being defiant or disruptive and not following guidelines and protocol set forth in this agreement, staff will call my parents to pick me up immediately. I also understand that if I am asked to leave camp for any reason, there will be no refund given. MOUNTAIN WISDOM, INC. | THIS IS A RELEASE OF LIABILITY READ IT CAREFULLY AND COMPLETELY BEFORE SIGNING CORONAVIRUS/COVID-19 | ACTIVITY PARTICIPATION ASSUMPTION OF RISK, RELEASE, WAIVER, AND DISCHARGE
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. It is believed that an asymptomatic individual can be infected and transmit COVID-19 without their knowledge.
Mountain Wisdom, Inc., has put in place preventative measures recommended by the State of Georgia, the American Camp Association and the Center for Disease Control and Prevention to reduce the spread of COVID-19, however Mountain Wisdom, Inc., cannot guarantee that you, your child(ren), your spouse, or anyone else will not become exposed to or infected with COVID-19 as a result of participating in a Mountain Wisdom Inc., camp, event or activity. Participation in a Mountain Wisdom Inc., camp, event, or activity could increase the risk of contracting COVID-19.
NOW, THEREFORE, in consideration of being permitted to participate in camps, programs, events and/or activities offered by Mountain Wisdom Inc., I understand, acknowledge and agree to the following:
I have independently evaluated and reviewed the risks of being exposed to or infected with COVID-19 and have determined to participate in Mountain Wisdom, Inc., camps, programs, events, and/or activities with full knowledge and acceptance of the risk. Fully understanding these risks, I, for myself, my child/ren, my spouse, my legal representatives, heirs, and assigns, hereby agree to assume full responsibility and liability for the risk of bodily injury, illness, permanent disability, and/or death which may result from exposure to or infection with COVID-19 before, during, or after participating in a Mountain Wisdom, Inc., camp, program, event, or activity.
THE RELEASEES INCLUDE:
I, for myself, my child(ren), my spouse, my legal representatives, heirs and assigns, hereby waive, release and discharge 1. Mountain Wisdom Inc., camps, events and or activities, Owners Jay and Terry Zipperman, individually or together along with all Directors, Board of Directors, officials, attorneys, volunteers, participants, staff, representatives, agents and all other persons or entities acting in any capacity on their behalf. 2. Robert Lipman and Tri-Mountain Retreat, 1163 Hard Slate Road Elliay, Ga 30536,(location of Day Camps) from any and all liability to me, my child(ren), my spouse, my legal representatives, heirs, and assigns for any and all losses or damages resulting from bodily injury, illness, permanent disability, and/or death, whether caused by negligence of 1. Mountain Wisdom, Inc., camps, events and or activities, Owners Jay and Terry Zipperman, individually or together along with all Directors, Board of Directors, officials, attorneys, volunteers, participants, staff, representatives, agents and all other persons or entities acting in any capacity on their behalf.
2. Robert Lipman and Tri-Mountain Retreat, 1163 Hard Slate Road Elliay, Ga 30536. (location of Day Camps) which claims, losses and demands arise during or result directly or indirectly from exposure to or infection with COVID-19 before, during, or after participating in a Mountain Wisdom, Inc., camp, program, event or activity. Submit Camper Information