For office use only
Cash/Check _________
Date paid ___________
Forms:
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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
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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.
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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 _____________
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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)
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