Crew Kids Ahoy! Registration Form - CrewNet

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 margaretvg@verizon.net.
 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 margaretvg@verizon.net 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