Virtual Activities

- January Virtual Activities*
  Select The Date/Time for sessions you would like. These classes are a 4 day series.
- January Virtual Activities - Second Choice*
  Select The Date/Time for sessions you would like. These classes are a 4 day series.
Would you like to register for another session in January?
- Yes
- No
- January Virtual Activities*
  Select The Date/Time for sessions you would like. These classes are a 4 day series.
- January Virtual Activities - Second Choice*
  Select The Date/Time for sessions you would like. These classes are a 4 day series.

- February Virtual Activities*
  Select The Date/Time for an AM or PM Group. These classes are a 4 day series.
- February Virtual Activities - Second Choice*
  Select The Date/Time for an AM or PM Group. These classes are a 4 day series.
Would you like to register for another session in February?
- Yes
- No
- February Virtual Activities*
  Select The Date/Time for an AM or PM Group. These classes are a 4 day series.
- February Virtual Activities - Second Choice*
  Select The Date/Time for an AM or PM Group. These classes are a 4 day series.

January 2-Day Retreat*
- Yes
- No
January 16-17th 10AM-1:40PM
February 2-Day Retreat*
- Yes
- No
February13-14th 4:30PM-7:40PM
Name*
First Last
Address Where Retreat Package Will Be Shipped.*
Street Address Address Line 2 City State ZIP Code

Your Name*
First Last
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?
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 Details
Brokerage 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*
Signature
Please use mouse cursor or fingers to electronically sign giving consent.

Virtual Programming