Virtual Programming Step 1 of 5 20% Select The Date/Time for a Group. These classes are a 4 day series. November: 3 DSA hours or $60/session Select All MHKC Fun & Yoga: Mondays 11 AM-12 PM MHKC Fun & Reality TV Show Games: Tuesdays 6-7 PM MHKC Fun & Dance: Wednesdays 4-5 PM MHKC Fun & Baking/Cooking Thursdays 4:30-5:30 PM - Class is Full MHKC Fun & Crafts: Fridays 3-4 PM December: 3 DSA hours or $60/session Select All MHKC Fun & Yoga: Mondays 11 AM-12 PM MHKC Fun & Reality TV Show Games: Tuesdays 6-7 PM MHKC Fun & Baking/Cooking Thursdays 4:30-5:30 PM MHKC Fun & Crafts: Fridays 3-4 PM Special Event: 2 DSA hours or $40 per event Spooktacular Pumpkin Bash – Thursday 10/28 3-5 PM Fall Fest – Monday 11/15 3-5 PM Winter Ball 12/1 3-5 PM Your Name* First Last Phone*Email* Participants Name* First Last Participant Age* Is the Participant a past MHKC Camper* Yes No Is the Participant going to be utilizing extra support from someone (participant provided) during the activities?* Yes No Please explain in detail what (Participant provided) extra support may be needed.Do you have access to a printer?* Yes No Do you have a Zoom account or have you used Zoom before?* Yes No Need More Information Will you be paying privately or billing to brokerage?PrivatelyBill To Brokerage Invoice will be sent through email from Square. This will need to be paid in full 7 days before the first class. If you need a payment plan, please sign up and contact Kathy Werschkul after submitting the form. Thank you Brokerage DetailsBrokerage Name Brokerage Personal Agent Name Brokerage Personal Agent Phone Number Brokerage Personal Agent Email Brokerage will be billed for 4 hours. Please contact your brokerage and add us as an approved provider if you already haven't done so to ensure processing. Thank you Media Release* I have read and agree to the terms and conditions above for photos/videos to be taken of the participant. I do not give permission for photos/videos to be taken of the participant to be used. I understand that photographs and videos may be taken during Virtual Day Support Activities showing the participant(s) and MHKC staff in their online activities. Some photographs/videos will be used by Mt. Hood Kiwanis Camp for both promotional and educational purposes in printed materials, on our website, and on other media platforms including but not limited to Facebook, Instagram, and Twitter. I further give permission and consent that any such photographs may be published and used by the American Camp Association and its agents, to illustrate and promote Mt. Hood Kiwanis Camp and its programs or the American Camp Association. I understand that Mt. Hood Kiwanis Camp will only use a participant's photo/video if I accept these terms.Participant Name* First Last Name of individual giving consent* First Last Relationship to Participant* SignaturePlease use mouse cursor or fingers to electronically sign giving consent. ACCEPTANCE CRITERIA AND AGREEMENT* I have read and agree to the terms and conditions below. I do not agree to the terms and conditions. Mt. Hood Kiwanis Camp accepts applicants regardless of race, color, national origin, sex, sexual orientation, gender identification, veteran status, or disability. The following basic criteria are used to determine acceptance: The applicant (1) must meet the minimum age requirement by the first day of programming,(2) must be able to benefit from the Virtual Programming setting, (3) must be adaptable to the Virtual Programming environment, (4) must not be physically, verbally, or sexually abusive, (5) must have no history of arson or fire setting AND (6) must be free of conditions and behaviors that might not be manageable in a virtual setting. See Program Eligibility Standards for detailed acceptance criteria. We (participant and parent/guardian) wish the applicant named above to participate in the Mt. Hood Kiwanis Camp program. We fully understand that by signing this agreement form we recognize that there may be risk of injury and/or illness during such participation and that certain dangers and accidents may occur. In consideration of participation in the program, we (participant and parent/guardian) hereby release and discharge the Mt. Hood Kiwanis Camp, its officers, agents, and employees; Kiwanis Clubs and their members; Portland State University, its employees and students; the State of Oregon; the U.S. Forest Service and the agents and insurers of each of them, from any and all claims, including negligence and breach of contract, because of any injury and/or illness to the applicant during participation in the program. Further, we agree to defend and indemnify the Camp, its officers, agents, and employees; Kiwanis Clubs and their members; Portland State University, its employees and students; the State of Oregon; the U.S. Forest Service and the agents and insurers of each of them, from actions for damages or expense caused to other participants in the program which are caused by our participant. We further agree that each person participating in the program must follow safety instructions, rules, and refrain from behavior that is harmful to themselves, or others. By signing this agreement we understand that failure to do so may be cause for the participant’s dismissal from the program at the discretion of the Programs or Assistant Programs Director. We understand that the applicant may be dismissed from the program for reasons including behavior, lack of attendance, injury, or verbal abuse. We also agree, by signing this agreement, that if the participant is dismissed from Virtual Programming we may not receive a monetary refund. Additionally, we understand that all of Mt. Hood Kiwanis Camp's employees and volunteers are mandatory abuse reporters. Any allegations or reasonable cause to suspect abuse or neglect will be reported directly to the Department of Human Services. We have read and understand the fee structure, refund, and balance-due policies and agree to pay as stated. We understand that acceptance to any MHKC program will not be allowed until all outstanding balances from previous programs are paid.Name of individual giving consent* First Last SignaturePlease use mouse cursor or fingers to electronically sign giving consent.