2021 Pono Grown Farm & Nature Camp Application Form Camper's Name* First Last Camper's Birth Date* Does camper have any allergies?* Yes No Please list all allergies and describe camper's response to exposure.* Does camper use an inhaler or epipen?* Yes No Does camper have any health concerns or medical conditions?* Yes No Please list all health concerns and medical conditions*Also describe any necessary medications or treatments that may affect his/her participation at camp. Does camper have any physical limitations?* Yes No Please describe camper's physical limitations.* Camper's Gender* Anything else you want us to know? Parent/Guardian's Name* First Last Relationship to camper* Parent/Guardian's Phone Number*Parent/Guardian's Email* Preferred Communication Method* Phone call Text message Email We will contact you as little as possible, but want to make sure that when we do it's as easy as can be, so let us know how you prefer to be reached. Additional Parent/Guardian's Name First Last Relationship to camper PhoneEmail Emergency Contact Name* First Last Please name SOMEONE OTHER than parent(s)/guardian(s) listed above. Parent(s)/Guardian(s) will be contacted first in case of an emergency. This gives us additional adults to contact in case we cannot reach you for some reason.Emergency Contact's Phone Number*Emergency Contact's Relationship to Camper* Camper Photo Release*I agree to have photos/videos of my child's camp experience taken and shared in future promotional efforts online and/or in print for camp. Yes No I agree to have camper photos taken, but not publically shared Liability Waiver* I give consent for my child to participate in Pono Grown camp activities, and execute the liability release described herein on his/her behalf. I agree to assume responsibility for all risks, injuries, damages (known or unknown) associated with my child's participation in Pono Grown camp activities. I also agree to inform the camp coordinator of any actions or movements, which I feel my child cannot safely perform. I will inform the camp coordinator of any limitations, medical conditions, or other special considerations that may affect my child's safety during these camp activities in Makawao, Hawaii. I discharge in advance Pono Grown LLC and all officers, employees, contractors, and volunteers from all liability related to my child's participation in and presence at camp. Furthermore, I forever waive any claim I, my heirs, or my legal representatives my have against the above mentioned persons and entities.COVID-19 Policies & Waiver* PLEASE READ CAREFULLY. We reserve the right to update this waiver at any time with notice. COVID-19 POLICY AGREEMENTS AS OF 3.18.21: * Families are responsible for their children’s ability to comply with all health protocols before sending them to camp. We reserve the right to suspend a camper or cancel a camp group if proper hygiene relating to thorough hand washing, coughing, nose blowing, etc. is repeatedly not happening. * Daily health screenings of staff and campers is required before entering the camp area upon arrival. Any camper or staff with a temperature of 100 degrees or higher will not be able to participate until his/her temperature has been below 99.5 for 72 hours without medication. * Campers may not attend camp if they, anyone in their household, or anyone with whom they have been in contact exhibits any symptoms of COVID-19 or tests positive regardless of symptoms within 14 days of camp. * Parents/Guardians are required to monitor campers for any symptoms of illness and to keep them home if they (or anyone in their home) have any of the following: chills, cough, shortness of breath, fatigue, runny nose, watery eyes, congestion, muscle aches, headache, loss of taste or smell, sore throat, skin rash, diarrhea, nausea, vomiting, and/or lice. * Families are asked to be very conscious of the safety of their family, social, and public activities in the 14 days leading up to camp and during the duration of camp itself in order to uphold the wellbeing of the group. * Campers with underlying health conditions are advised to consult with their doctor about the decision to attend camp. * Parents/Guardians are required to wear masks at drop-off and pick-up, and are asked to take care of all preparations such as applying sunscreen at their cars in the parking lot or before arriving at camp. Parents are asked to say their goodbyes after the health screening, and not to enter the camp area. Parents are also asked not to congregate with each other in the parking lot and if communication is necessary to remain masked and socially distant from members of other families. * While we will follow all CDC, state and county requirements to the best of our ability, and are implementing enhanced cleaning protocols, we are not able to guarantee the health of your child or family. * I have thoroughly read and voluntarily agree to the participation terms and health protocols listed above. * ASSUMPTION OF RISK: I assume the risk that my child, myself, and other family members may be exposed to or infected by COVID-19 by attending any camps and activities at Pono Grown, and that such exposure or infection may result in personal injury, illness, permanent disability or death. I hereby choose to accept these risks in order to enroll my child in Pono Grown Farm & Nature Camp. * WAIVER OF LAWSUIT/LIABILITY: I understand that the risk of becoming exposed to or infected by COVID-19 at Pono Grown Farm & Nature Camp may result from actions, omissions, or negligence of myself, my child and others, including, but not limited to, Pono Grown LLC employees, contractors, volunteers, or other campers and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injuries to my child, myself, and other family members (including, but not limited to, personal injury, disability or death), illnesses, damages, losses, claims, liability, costs or expenses, of any kind (collectively, “Claims”), that I, my child and our family may experience or incur in connection with my child’s attendance at Pono Grown Farm & Nature Camp. I hereby forever release and waive my right to bring suit against Pono Grown LLC and its agents and employees, contractors, volunteers, and other representatives in connection with exposure, infection and/or spread of COVID-19 related to utilizing Pono Grown’s services and premises. I understand that this waiver means I give up my right to bring any claims including for personal injuries, death, disease or property losses, or any other loss, including but not limited to claims of negligence and give up any claim I may have to seek damages whether known or unknown, foreseen or unforeseen.Consent for Treatment* I give consent to have my child treated by emergency medical personnel, a physician, or surgeon in the case of sudden illness or injury while participating in Pono Grown Camp activities. I understand that any necessary medical treatments will be my expense.Electronic Signature* I have read the above parental consent form, waivers of liability, and COVID policies. I fully understand their contents, and agree to all of their terms and conditions. I agree that all the information contained in this application is accurate and will notify camp coordinator immediately with any changes.My name entered here serves as my electronic signature* Date* MM slash DD slash YYYY Pono Grown Camp Options* 10 Weeks $2,000 9 weeks $1,980 8 weeks $1,760 7 weeks $1,680 6 weeks $1,440 5 weeks $1,300 4 weeks $1,040 3 weeks $840 2 weeks $560 1 week $300 Camp Week Selection* Select All Week 1: June 8 - 11, 2021 (FULL - waitlist only) Week 2: June 15 - 18, 2021 (FULL - waitlist only) Week 3: June 22 - 25, 2021 (FULL - waitlist only) Week 4: June 29 - July 2, 2021 (FULL - waitlist only) Week 5: July 6 - 9, 2021 (FULL - waitlist only) Week 6: July 13 - 16, 2021 (FULL - waitlist only) Week 7: July 20 - 23, 2021 (FULL - waitlist only) Week 8: July 27 - 30, 2021 (FULL - waitlist only) Week 9: August 3 - 6, 2021 (FULL - waitlist only) Week 10: August 10 - 13, 2021 Siblings*Does your camper have a brother or sister who is also attending Pono Grown camp this summer? No Yes Sibling Discount Price: $0.00 How did you hear about camp?* Coupon Code Coupon can't be combined with sibling discount, and is only applicable to week 10 in our 2021 camp. CAPTCHAPayment Options*No deposit is required to join the waitlist should all the spaces in your desired week(s) fill. If a space opens, a $100/week deposit is required to hold your camper's spot. We will hold your child's spot for 5 days after application is received. If payment has not been made within 5 days, their spot will no longer be reserved. The remainder of your balance will be due two weeks before your camper's start date. The deposit is non-refundable except if the camp week(s) you've selected are canceled due to COVID-19. I will Mail a check to Pono Grown at 677 Olinda Road, Makawao, HI 96768 Arrange to drop off cash Pay by credit card with an additional 3% processing fee Join the waitlist with no deposit required Credit Card Processing Fee* Price: $0.00 Total $0.00 Credit CardCard Details Cardholder Name
