Child Information
Primary Contact
Secondary Contact
Emergency Contact
Participation Waiver
Please read carefully and sign below. I, the undersigned, understand that each of
Miramont Country Club, its parent companies, affiliates and inter-related companies
(collectively, “Miramont Country Club”) assumes no responsibility for injuries or
illnesses, which my child may sustain as a result if his/her physical condition or
resulting from his/her participation in any athletic activities, sports program, the use of
any equipment, exercise or other activities. I expressly acknowledge on behalf of myself
and my heirs that I assume the risk for any and all injuries and illness, which may result
from his/her participation in these activities and I hereby release Miramont Country
Club, its agents, servants and employees from any and all claims of injury, illness, death,
loss or damage which he/she may suffer as a result of his/her participation in these
activities. I recognize that Miramont Country Club will make every reasonable effort to
minimize exposure to known risks associated with the program. I understand that
Miramont Country Club is not responsible for personal property lost or stolen while
Members and/or program participants are using the Miramont Country Club facilities
on Miramont Country Club premises. I give permission to Miramont Country Club to
use, without limitation or obligation, photographs, film footage, my child’s image or
voice for purpose of promoting or interpreting Miramont Country Club programs. I
acknowledge the Waiver as set forth.
Transportation Agreement
Your child may be using golf cart transportation provided by Miramont Country Club.
This will be for transportation around the Club. By my signature below, I give
permission for my child to travel by golf cart with Miramont Country Club staff.
Illness
In the case that your child becomes ill during the program, you will be contacted as soon
as possible. If the parent or guardian is unable to be reached, the child’s emergency
contact will be notified. It is the responsibility of the parents or guardians to arrange for
the child to be picked up from the facility as soon as possible. In the case that your
camper or anyone in the immediate household of the camper develops a reportable
communicable disease as defined by the State Board of Health, it is the responsibility of
the parent or guardian to notify Miramont Country Club within 24 hours or the next
business day in order for Miramont Country Club to take proper action, except in the
case of life threatening diseases, which must be reported immediately.
Emergency Authorization
Please read carefully and sign below. My signature authorizes the management and staff
of Miramont Country Club to act for me according to their best judgment in the event of
a medical emergency and/or routine medical care. By my signature I hereby waive,
release and hold harmless Miramont Country Club, its management, volunteers, agents
and staff from any and all liability for any injuries, death or illness sustained and/or
incurred while at camp and/or while using any facilities of, or participating in any of the
activities or Miramont Country Club. I/we grant permission for emergency medical
treatment and/or routine medical care by the Miramont Country Club camp staff, an
ambulance, or private physician and/or hospital or emergency health care staff, under
the same circumstances as above, if needed. Any such action will be taken in the best
interest of my child and will be reported to me/us as soon as possible. My signature
waives and/or releases Miramont Country Club from any and all liability and/or
financial responsibility for any medical expenses incurred.
Waiver of Liability
The signature below signifies acceptance of the following waiver of liability. I
acknowledge that Miramont Country Club may compile address labels and lists and may
utilize photographs of the named individual. I consent to these uses of my name, address
and likeness and hereby waive all rights to compensation for their use in the promotion
and/or operation of Miramont Country Club.
To induce Miramont Country Club to accept registration and permit participation in
Miramont Country Club sports programs, I hereby give my consent and agree to release,
indemnify and hold harmless Miramont Country Club its officers, officials, coaches,
employees and representatives from any claim arising out of injury to the named
individual. I also hold harmless Miramont Country Club, its officers, officials, coaches,
employees and representatives from and against any claim arising out of injuries or
conditions caused by or aggravated by my refusal to obtain available medical treatment
based on religious or philosophical beliefs or otherwise.
I understand that as a participant in Miramont Country Club sporting events that I must
abide by all rules, regulations and philosophies of Miramont Country Club.
Health Report & Comments on Child's Development
Medical Attention
In emergencies requiring medical attention, your child will be taken to the nearest hospital emergency room. Your signature below authorizes a representative of Miramont Country Club to have your child transported to the hospital.
Medication
Prescription medication or over-the-counter medication will not be administered. Do not send medications with your camper. Children are not permitted to keep medications in their book bags or pockets. The only two forms of medication that are allowed will be inhalers and epinephrine pens. Inhalers and epinephrine pens must be handed to the staff member at the check-in by the parent. Inhalers and epinephrine pens will be kept by the staff.
