For office use only Cash/Check _________ Date paid ___________ Forms: ___Page 1 ___Page 2 ___Page 3 ___Page 4 Adventure Day Camp August 4, 5, 6, 2015 Registration and Medical Information Form Open to youth 6 to 11 years old All Forms and payment must be received by July 17, 2015 at 5:00 p.m. SPACE IS LIMITED TO THE FIRST 100 PAID REGISTRATIONS Please complete all pages - front and back. Return completed forms to: CSU Extension 701 Court Street, Suite C Pueblo, CO 81003 Make check for $15.00 payable to: Extension Program Fund Please print clearly. Student name: Address: Zip: _____________ Phone: Birth date: ________ Emergency phone: _________________________ Age as of 08/01/15: ______ (must be 6) Sex: M F Grade Completed :________ Parent(s)/Guardian(s): Address: Zip: _____________ Home phone: Work phone: Cellular phone: E-mail: Emergency information If we are unable to reach parent/guardian in an emergency, whom should we contact? 1. Name: _______________________________ 2. Name: ________________________________ Relationship to student: __________________ Relationship to student: ___________________ Home phone: __________________________ Home phone: ___________________________ Work or cellular: ______________________ Work or cellular: _________________________ In addition to the people listed above, these people are authorized to pick up my child: 1)_________________________________(relationship to child) 2)_________________________________(relationship to child) 3)_________________________________(relationship to child) Ethnicity (check one) ____ Hispanic Race (check all that apply) ____ White ____Hawaiian/Pacific Islander T-Shirt Size Y=youth sizes A=adult sizes __YM __YL __YXL __AS __AM __AL __AXL ____ Non-Hispanic ____ Black ____Alaskan/Am. Indian ____Other (please list) ____Asian Page 1 Medical Information Form Health history Does you child have any serious health challenges? Yes No If so, please describe: _____________________________________________________________________________________ Does your child have any allergies? Yes No Describe: ____________________________________ Does your child have any dietary restrictions? Yes No Is your child currently taking any medications? Yes No Describe: ____________________________ If yes, please list those medications your child will need to bring. _____________________________________________ The Adventure Day Camp will have sunscreen, insect repellent (DEET) and analgesics (Tylenol, Ibuprofen) available. May the camp director/counselors administer these products to your child as needed? Yes No Restrict the use of ____________________________________________________ AUTHORIZATION FOR MEDICAL CARE Authorization for medical care: I hereby give my permission to allow officials to call a doctor or emergency medical service and for the doctor, hospital or medical service to provide emergency medical or surgical care for my child, ___________________________, should an emergency arise. It is understood that event officials will make a conscientious effort to locate the emergency contacts listed on this document before any action will be taken. If it is not possible to locate emergency contacts listed, I/we will accept the expense of emergency medical or surgical treatment. Insurance Company ______________________________________________ Policy #____________________________________ Subscriber name and address: _________________________________________________________________________________ Parent or Guardian signature: __________________________________________________ Date:___________________________ _____ I do not wish my child to have emergency medical care. Page 2 READ THIS DOCUMENT COMPLETELY BEFORE SIGNING. ITS EFFECT IS TO RELEASE COLORADO STATE UNIVERSITY, ITS GOVERNING BOARD, THE STATE OF COLORADO, AND PUEBLO COUNTY FROM ANY LIABILITY RESULTING FROM YOUR CHILDS PARTICIPATION IN THE ACTIVITIES DESCRIBED BELOW, AND TO WAIVE ALL CLAIMS FOR DAMAGES OR LOSSES AGAINST THE UNIVERSITY, STATE OF COLORADO, AND PUEBLO COUNTY WHICH MAY ARISE FROM SUCH ACTIVITIES. Permission for Youth to Participate in Adventure Day Camp I hereby give permission for ____________________________________ to participate in organized activities offered by Adventure Day Camp through CSU Extension – Pueblo County. It is my understanding that my child will participate in activities that may be physically challenging. We also agree to follow the Code of Conduct. Release From Responsibility, Assumption of Risk, and Waiver STUDENT’S FULL NAME: DATE OF BIRTH (MO/DAY/YR): ADDRESS: DATE OF ACTIVITY: START DATE: 08/04/15 Activities: Day Camp Activities END DATE: 08/06/15 I, the undersigned parent or guardian of the above named participant, hereby release and discharge, indemnify and hold harmless The Board of Governors of the Colorado State University System and Colorado State University, Pueblo County, and their members, officers, agents, employees, and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against any and all claims, demands, and causes of action whatsoever, whether presently known or unknown, either in law or in equity, relating to injury, disability, death or other harm, to person or property or both, arising from my child’s participation in and/or presence at the above listed activities. I acknowledge that I have been informed of the nature of the activities and that I am aware of the hazards and risks which may be associated with my child’s participation in the above-named activities, including the risks of bodily injury, death or damage to property which may occur from known or unknown causes. I understand, accept, and assume all such hazards and risks, and waive all claims against the State of Colorado, The Board of Governors of the Colorado State University System, and Colorado State University, Pueblo County and other persons as set forth above. I understand that I am solely responsible for any costs arising out of any bodily injury sustained through my child’s participation in normal or unusual acts associated with the above-named activities. I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily give my consent and agree to this Release from Responsibility, Assumption of Risk, and Waiver. READ, UNDERSTOOD AND AGREED TO THIS DAY OF , 20 . I, (printed name) ________________________________________________, am the parent or legal guardian of the participant who has signed above. I have read and I understand the provisions of this document, I consent to the participant taking part in the activities described above, and I fully enter into and agree to the above Release From Responsibility, Assumption of Risk, and Waiver. Parent signature _____________________________ Date _________ Witness _____________ Page 3 There are 2 release forms on this paper. Please sign and date both boxes. Student Name (please print) _____________________________________________ Parent/guardian (please print) ____________________________________________ Code of Conduct Youth, leaders, parents and other adults participating in this activity will: 1. Adhere to program rules, dress codes, policies, and rules of the facility being used. 2. Conduct themselves in a courteous, respectful manner, use appropriate language, exhibit good sportsmanship. 3. Fully participate in activities. 4. Respect others. 5. Adhere to rules of safety Consequences for violating any of these codes may include removal from the activity or dismissal from camp. Signature of Parent or Legal Guardian________________________________________________Date__________________ __________________________________ _______________________________________ (Student signature) (Parent/guardian signature) __________ (Date) PHOTOGRAPHY CONSENT FORM RELEASE FOR MINOR CHILDREN (Under 18) I, (print name)___________________________________________, parent or official guardian of (student’s name)____________________________________________hereby _______ grant permission to Colorado State University Extension, its employees or representatives, to take and use photographs, including digital photos and videotape of my child for use in promotional or educational materials including printed publications or materials, electronic publications or presentations, and web sites. I agree that my child’s name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images indefinitely without compensation to me. All negatives, positives, prints, digital reproductions and videotape shall be the property of Colorado State University Extension. _______ deny permission to Colorado State University Extension, its employees or representatives, to take and use photographs, including digital photos and videotape of my child for use in promotional or educational materials including printed publications or materials, electronic publications or presentations, and web sites. ____________________________________ (Date) ____________________________________ (Signature of Parent or Guardian) ____________________________________ (Address) ____________________________________ (City, State, Zip) Page 4
© Copyright 2024