AKM SUMMER CAMP 2019
CHILD INFORMATION SHEET

Summer Camp Child Information Form

To register for a camp, please complete this form and submit payment using the link for each session. This form is to provide necessary details about the child you are wishing to register, but is not a registration form. Registration cannot be confirmed until payment has been received.

Please be aware that while we do our best to keep this form up-to-date, camps do sell out and you should refer to the camp event page for the most up-to-date information on availability.

For questions, please contact us at: 416.646.4677x7726 or learn@agakhanmusuem.org



AGA KHAN MUSEUM SUMMER CAMP 2019 CHILD INFORMATION SHEET

Packed with hands-on activities for kids between the ages of 6 and 12, our Summer Camps are offered in four exciting sessions this July and August. Campers use our galleries for inspiration as they create their own masterpieces during each fun-filled week.

PROGRAM SELECTION:

If your child is interested in attending more than one session, you can select multiple sessions below.
A separate form is required for each child.

NOTE: To enroll in an age group, child must be the appropriate age by the start of the camp.

Date:Monday, July 8 to Friday, July 12, 2019, 9 am—4 pm

Price: $300 per child; $270 for children of Friends; 10% discount for siblings

Date: Monday, July 15 to Friday, July 19, 2019, 9 am—4 pm

Price: $300 per child; $270 for children of Friends; 10% discount for siblings

Date:Monday, July 22 to Friday, July 26, 2019, 9 am—4 pm

Price: $300 per child; $270 for children of Friends; 10% discount for siblings

EXTENDED CARE (After-Hours Supervision from 4-6 pm)

Supervised extended care fee is an additional $60 per child, per week* for the Summer Camp Program from 4–6 pm. Museum doors close at 6 pm sharp. Please note extended care requires a minimum number of registrants.

* A surcharge will be applied for late pick-ups after 4 pm for those not enrolled in after-hours care, and late pick-ups after 6 pm for those enrolled in after-hours care.

PLEASE READ CAREFULLY, FILL THE FORM AND SUBMIT.

INFORMATION FORM:
PERSONAL INFORMATION:

Information collected on this application form, including personal information, will be used by the Aga Khan Museum to register the herein named child in the Summer Camp and to communicate with you and the child in connection with such program and for such other purposes as described in these forms. For more information on the Museum’s privacy policy, please visit https://www.agakhanmuseum.org/privacy-policy

PARENTAL CONSENT (REQUIRED): [Please read carefully and indicate your acceptance by confirming acceptance at the bottom of this section.]:

I hereby apply for registration for the herein named child for the Summer Camp(s) indicated in this application. In consideration of acceptance of this application by the Aga Khan Museum and participation in the Summer Camp(s), I hereby agree as follows on behalf of myself (where applicable) and my child:

a. To allow my child to participate in all Summer Camp activities.

b. That the Aga Khan Museum reserves the right to terminate the registration of my child in the Summer Camp when it is deemed in the best interests of the child or the Aga Khan Museum.

c. To give the Aga Khan Museum officials authority to act on my behalf in case of emergency and in the best interests of my child if I am not present at the time of the emergency.

d. That, in the event of an illness, injury or other emergency suffered by my child during the Summer Camp, I understand and agree that the Aga Khan Museum will obtain the necessary medical attention for the child participant, which may include administering medicines, basic First Aid, and transportation to the nearest hospital. I further agree that no official or volunteer will be held responsible for injuries or damages arising from the provision of any such emergency medical treatment.

e. That my child will comply with the rules and policies of the Aga Khan Museum and the Summer Camp instructors and failure to do so may result in termination of participation in the Summer Camp.

f. That my child is solely responsible for his/her personal effects and belongings, including but not limited to money, clothing, and personal items brought to the Summer Camp(s).

g. To release, hold harmless and forever discharge the Aga Khan Museum and each of their respective directors, officers, trustees, members, employees, volunteers and agents (collectively the “Releasees”) from any and all liability, actions, causes of action, claims and demands resulting from any loss, injury or damage to person or property that I or my child may suffer in connection with my child’s participation in the Summer Camp due to any cause whatsoever, INCLUDING NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE RELEVANT OCCUPIERS LIABILITY ACT OR ANY OTHER RELEVANT STATUTES, on the part of the Releasees.

h. TO NOT SUE THE RELEASEES or any of them for any loss, injury, costs or damages of any form or type, howsoever caused or arising, and whether directly or indirectly from the participation of my child in the Summer Camps.

i. TO INDEMNIFY, and to SAVE and HOLD HARMLESS the RELEASEES, and each of them, from any litigation expense, legal fees, liability, damage, award or cost, of any form or type whatsoever, they may incur due to any claim made against them or any one of them whether the claim is based on the negligence or the gross negligence of the Releasees or otherwise.

j. That I have read this document and all the forms thoroughly and understand their terms.

I HAVE READ AND UNDERSTAND THIS AGREEMENT AND ALL ASSOCIATED PERMISSION FORMS. I AM AWARE THAT I AM WAIVING CERTAIN SUBSTANTIAL LEGAL RIGHTS WHICH MY CHILD, HIS/HER HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS AND I MAY HAVE AGAINST THE RELEASEES.

I CONFIRM ACCEPTANCE OF THE CONTENTS OF THIS DOCUMENT AND ALL PERMISSION FORMS VOLUNTARILY AND WITHOUT INDUCEMENT.

I CONFIRM THAT I AM THE PARENT/GUARDIAN HAVING FULL LEGAL RESPONSIBILITY FOR DECISIONS REGARDING THE ABOVE CHILD.

PICK-UP PERMISSION

Please indicate below ALL individuals who have permission to pick up your child from the Summer Camp, INCLUDING the parent/guardian(s) AND the person who registered the child, if he or she is also authorized to pick up your child. Those picking up a child MUST have a valid piece of photo identification (driver’s license, etc.) to verify their name on the pick-up list

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If a change to the above selection is required, please call 647-808-4391 and email the Education Team at learn@agakhanmuseum.org to confirm the new instructions.
Note that the Aga Khan Museum will rely on the above instructions for the duration of camp unless alternate instructions are provided in writing by the parent/legal guardian.

PHOTOGRAPHY AND VIDEO PERMISISSION :

During the course of this Aga Khan Museum (“Museum”) program, images may be taken of your child(ren) and/or your child(ren)’s artwork for use in the marketing, advertising, and promotion of Aga Khan Museum programs and fundraising campaigns. No personal identifying information (i.e., name/address) will be associated with the use of the image. If you give permission for your child(ren)’s image to be used as described above, please sign this consent where indicated below.

I, the undersigned on behalf of my minor child(ren), give permission to the Museum to use, share, disclose, and publish photographs, videos, and other recordings (including audio) of my child(ren) and their likeness and their artwork, without restriction. I also give permission to the Museum to modify and edit (e.g., crop, adjust colouring, etc.) or create derivative works of same such photographs, videos, other recordings, and artwork as needed or as may be desirable for use and/or publication. I hereby waive any right to inspect or approve the use of the images or recordings or of any written copy.By giving this consent on behalf of my minor child(ren), I understand and acknowledge that I am hereby irrevocably granting permission to the Museum the right to use and incorporate (alone or together with other materials) to perpetually, exclusively use photographs, video, and/or other recordings taken of my minor child(ren) and their artwork (in whole or in part) as a result of their participation in activities/events of the Museum or otherwise for all media throughout the world (including audio, print, film, slides, non-theatrical, home video, CD-ROM, Internet, and any other electronic medium presently in existence or invented in the future) .

I understand that neither I nor my child(ren) will be paid any compensation of any kind and I, on behalf of myself and my child(ren), waive any right to royalties or other compensation arising from or related to the use of the images, recordings, or materials. I acknowledge that the Museum owns all rights to the use of the images and recordings.

I, on behalf of my minor child(ren), forever release and discharge the Museum and all of its directors, officers, employees, members, agents, volunteers, and representatives (collectively, the “Releasees”) from any and all liability for any claim, action, demand, or controversy, including claims of invasion of privacy or violation of publicity rights, that I or my minor child(ren) might otherwise have in connection with the use of my minor child(ren)’s photos, videos, recordings, likeness, and artwork. This consent, waiver and release is binding on me, my child(ren) and our respective heirs, executors, administrators, and assigns.

HEALTH INFORMATION, EMERGENCY PLANS AND HEALTH PERMISSION FORM (REQUIRED)

The personal information contained on this form and the registration form will be used to respond to medical and emergency situations and is collected in accordance with the principles of applicable privacy law. This form must be completed and submitted for each child prior to the start of the Summer Camp. The form will be kept on file together with the child’s Summer Camp registration form, and copies of same may be shared with the Camp Supervisor(s).
Please provide detailed information and describe the necessary action required in the event of a medical emergency or allergic reaction. In addition, please speak with the Museum Camp Supervisor regarding your child’s allergies, medical conditions, and necessary medication.
1. Please provide information about any medical and/or behavioral conditions (e.g., asthma, diabetes, epilepsy, heart disease, sight/hearing difficulties, ADHD, emotional concerns, developmental delays, learning difficulties, etc.) that will help our Educators provide a successful learning experience for your child:
2. Please provide further information below, including medication and treatment (e.g. EpiPen®, inhaler, Ritalin, etc.)

ANAPHYLAXIS EMERGENCY PLAN (complete if applicable)

The registrant child has a potentially life-threatening allergy (anaphylaxis) to (check the appropriate boxes) :

Person is at greater risk. If person is having a reaction and has difficulty breathing, give epinephrine auto-injector before asthma medication.

Food

The key to preventing an anaphylactic emergency is absolute avoidance of the allergen. People with food allergies should not share food or eat unmarked/bulk foods or products with a “may contain” warning. Please note that the Museum is not a Nut-Free environment.

Epinephrine Auto-Injector:
Dosage:
Location of Auto-Injector(s):
MUSEUM EMERGENCY RESPONSE PLAN TO AN ANAPHYLATIC REACTION

A person having an anaphylactic reaction might have ANY of these signs and symptoms:

  • *
    Skin: hives, swelling, itching, warmth, redness, rash
  • *
    Respiratory (breathing): wheezing, shortness of breath, throat tightness, cough, hoarse voice, chest pain/tightness, nasal congestion or hay fever-like symptoms (runny, itchy nose and watery eyes, sneezing), trouble swallowing.
  • *
    Gastrointestinal (stomach): nausea, pain/cramps, vomiting, diarrhea.
  • *
    Cardiovascular (heart): pale/blue skin colour, weak pulse, passing out, dizzy/lightheaded, shock.
  • *
    Other: anxiety, feeling of “impending doom,” headache.

Act quickly. The first signs of reaction can be mild, but symptoms can get worse very quickly.

  • 1
    Give epinephrine auto-injector (e.g., EpiPen® or TwinjectTM) at the first sign of a reaction occurring with a known or suspected contact with allergen. Give a second dose in 10 to 15 minutes or sooner.
  • 2
    Call Museum Security 7777, or if outside the Museum, call 911. (Explain that someone is having a life-threatening allergic reaction. Ask them to send an ambulance immediately.
  • 3
    Go to the nearest hospital even if the symptoms are mild or have stopped.
  • 4
    Call emergency contact person. The undersigned parent or guardian authorizes the Aga Khan Museum staff or representatives to administer epinephrine to the above-named child in the event of an anaphylactic reaction, as described above.

Please review this Emergency Plan with your physician.

HEALTH PERMISSIONS AND CONSENTS (REQUIRED)

I, the undersigned, agree as follows on behalf of myself (where applicable) and my child whom I am registering for the Summer Camp(s):

  • a.
    I have read and understood the Health Form and agree to the terms therein contained.
  • b.
    I understand and acknowledge that while the Museum is a nut aware environment, it is not a nut-free environment.
  • c.
    I have read and understood the Museum’s emergency response plan in the event of a person having an anaphylactic reaction and agree that it meets the standard of care required for my child.
  • d.
    I give permission to the Aga Khan Museum to share this completed Health Form to attending Aga Khan Museum staff, agents and volunteers who have a need to know such information in connection with the implementation of the Summer Camp(s) in which my child is participating.




REMINDER: This form is to provide necessary details about the child you are wishing to register, but is NOT a registration form. Registration cannot be confirmed until payment has been received. For questions, please contact us at: 416.646.4677x7726 or learn@agakhanmusuem.org

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