Rewired 2024 Registration Please enable JavaScript in your browser to complete this form. - Step 1 of 3I, the undersigned parent/guardian, hereby consent for my child, *to participate in:Event InformationWe are extremely excited to announce REWIRED 2024 for students in grades 7- 12th. Cost is $80.00 per student plus $20 for optional REWIRED souvenir shirt. Transportation, meals, and activities are included in registration fee. Registration, Form, and Money are due by March 15, 2024. Date: APRIL 11-12, 2024 (Overnight) Location: CAMP SORENSON, Co Rd 121, Hilliard, FL 32046 Students and staff will travel via bus to the location. Students should arrive at SCA by 8am the morning of Thurs, April 11th. Legal AgreementI certify that my child is able to participate in the above activities. If my child has medical conditions that may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize SCA Staff to make emergency medical decisions for my child. If there are any activities I do not want my child to be involved in, I have listed them below. I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITY, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO, INCLUDING TRANSPORTATION TO AND FROM THIS EVENT. In consideration for my child being permitted to participate in the activity, I do hereby agree to hold the School, and its agents, employees, and volunteers harmless from, and to indemnify for, any and all liability, actions, causes of actions, claims, expenses, including attorney’s fees, and damages on account of injury to my child, even injury resulting in death, which I now have or which may arise in the future in connection with my child’s participation in the activity and any other associated activities. I further agree to hold the School, and its agents, employees, and volunteers harmless from, and to indemnify for, any and all liability, actions, causes of actions, claims, expenses, including attorney’s fees, and damages on account of injury to a Third Party or his property which may arise in the future in connection my child’s participation in the activity and any other associated activities. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand. LayoutParent Name *FirstLastParent Phone *Parent Email *Date *Parent SignatureClear SignatureMedical conditions to be aware of:I would like to purchase my child a Rewired shirt:YesNoSize for Rewired shirt:XSSmallMediumLargeXL2XL3XLTelephone numbers where I may be reached in case of an emergency: LayoutPhone(Other) PhoneSelect one:I do NOT with my child to participateOvernightDay ONLY (Must attend BOTH days)Parent is responsible for pickup (10pm) and drop off next day (8:45am).NextSave and Resume LaterFlorida Sheriffs Youth Ranches Camp Informed Consent / Medical Information / Photo Release I understand that my participation in programs with the Florida Sheriffs Youth Ranches, Inc. is entirely voluntary. I release Florida Sheriffs Youth Ranches, Inc., its employees, staff, and other agents from any claims or liability arising out of my participation. I am not under the influence of any chemical substance including alcohol. I understand that any physical activity involves the risk of increased heart rate and/or injury. LayoutChild's Name *FirstLastPhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutName of Personal PhysicianName of Emergency ContactDo you have health/accident insurance?YesNoPhonePhoneIf YES, please list carrier/policy number:Do you have any limiting physical or health disabilities or handicaps (temporary or permanent)?YesNoIf YES, please explain:Are you taking any medications, prescribed or otherwise?YesNoIf YES, please list medication and condition:List any known allergies to medications or otherwise:If you are allergic to insect bites/stings, do you have appropriate medication?LayoutDo you wear contact lenses?YesNoAre you pregnant?YesNoDo you currently have any of the following symptoms or conditions: (Check if yes)Heart Disease or Heart AttackAsthmaHigh Blood PressureEpilepsyChest Pains, palpitations, heart murmurDrug ReactionsHave you ever had a stroke?Back, neck, or knee problemsDo you have diabetes?History of heart disease, high blood pressure, or stroke in family?If you checked any of the above, please explain each:Have you had any recent injuries? Please explain:List any other conditions we should be aware of:I hereby consent to and authorize the use and reproduction by the Florida Sheriffs Youth Ranches, Inc. of any photographs, video, and sound recordings taken of me during this program for any media or marketing use. (Check if no)NoSignature of ParticipantClear SignatureDateWitnessClear SignatureDate**Parent/Guardian signature if Participant is under 18:Clear SignatureNextSave and Resume LaterYou can remit payment for registration using this form or by calling our school office at (904) 879-1260. Registration FeePrice: $80.00Rewired ShirtPrice: $20.00Help offset processing costs? *Yes - $3.29No - $0.00Stripe Credit Card *SubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link
