PACKET ONE:
TEAM REGISTRATION
(All Section One Documents MUST
be submitted to reserve a team to camp).
How to fill out PACKET ONE::
1).
Section One:
Complete the Team Information.
2).
Section Two:
Complete the Code of Conduct Statement and
Carthage College Organization Camp
Agreement.
3).
Section Three:
Complete the Registration Information.
SECTION
ORGANIZATION NAME:
TEAM COLORS:
ONE: TEAM INFORMATION
MAIN ORGANIZATION CONTACT PERSON’S INFORMATION NAME:
E-MAIL ADDRESS:
DAY PHONE:
MAILING ADDRESS:
CITY:
8
NIGHT PHONE:
STATE:
ZIP:
PACKET ONE (Continued):
(All Section One Documents MUST
be submitted to reserve a team to camp).
SECTION TWO: IRCA CODE OF CONDUCT STATEMENT AND
CARTHAGE COLLEGE ORGANIZATION CAMP AGREEMENT
(Page 1 of 2)
IRCA CODE OF CONDUCT STATEMENT
TheIllinoisRecreationalCheerleadingAssociation(IRCA)believesinpresentinganhonest,fairandcompetitiveformatforits
membersandourathletes.Thisfoundationisthebasisofallcompetitiveevents,andasaparticipant,weagreetoadhereto
the rules, regulations and definitions in the placement of all teams within the Divisions and Categories as outlined in the
IRCARules&Regulationsandtherulesofthiscompetition.
Eachprogramhasaresponsibilitytopromotethepremiseofintegritytoitsmembers.Inthespiritoffairnesstoallofthe
participants, our organizations acknowledgment below signifies that our program has represented our athletes in
accordancewiththisstatement.
Additionally,thespiritofcompetitionisbasedoffoftheleadershipofourorganizationtoadheretotheestablishedrules,
regulationsanddefinitionsandtaughttothechildrenofallofourorganization.Conductviolationssetanegativeimageof
oursportandaredetrimentaltoteachingvaluestoourathletes.
Asasubmittingorganization,werecognizethatviolationsoftheserulesareconsidereddamagingtotheIllinoisRecreational
CheerleadingAssociationanditsmembers.Wewilladheretotheseestablishedrulesandregulationsandfurtherrepresent
thatallofourteams,managersandcoacheswillcomplyaccordingly.
Furthermore, we understand that it is our responsibility to have completed and submitted to the Illinois Recreational
Cheerleading Association participant waivers forms (in there entirety) prior to camp participation. Our organization shall
assume all liabilities associated with not submitting parental waivers and defend the Illinois Recreational Cheerleading
Association for actions against the Illinois Recreational Cheerleading Association (IRCA) and American Recreational Cheer
leading,Inc.forlossesordamageswhichmaybesufferedagainsttheIllinoisRecreationalCheerleadingAssociation(IRCA)
andAmericanRecreationalCheerleading,Inc.fromnotsubmittingsaidwaiverdocuments.
COLLEGE INDEMNITY AND DAMAGES, RULES AND
REGULATIONS AND RIGHTS
OrganizationagreesthatallparticipantsareunderthedirectandcompletesupervisionandcontroloftheOrganization.As
such,Organizationisliableforalldamagesresultingfromparticipantutilizationofthefacilitiesandservicesprovidedbythe
College.OrganizationshallalsoreimbursetheCollegeforalldamagestofacilitiesandservicesoftheCollegeresultingfrom
theuseofthosefacilitiesandservicesbyOrganizationand/oritsparticipants.Inaddition,thetermsandconditionsofthe
agreementdonotrequiretheCollegetorelinquishitscontrolofitsfacilitiesandservicestotheOrganization.TheCollege
assumesnoresponsibilityforlossortheftofpersonalproperty,ordamagestopersonalpropertyofOrganizationoranyofits
participants.OrganizationshallindemnifyandholdharmlessCarthageCollege,itsofficesandemployeesagainstanyandall
claimsforloss,injuryordamagetopersonsorproperty,includingclaimsofemployeesofOrganizationoritsagentsarising
out of activities conducted by Organization or its guests on or in College buildings, properties, or facilities. The College
assumesnoliabilitywhatsoeverforanypropertyplacedbyOrganizationinCollegebuildings,properties,orfacilities.
9
PACKET ONE (Continued):
(All Section One Documents MUST
be submitted to reserve a team to camp).
SECTION TWO: IRCA CODE OF CONDUCT STATEMENT AND
CARTHAGE COLLEGE ORGANIZATION CAMP AGREEMENT
(Page 2 of 2)
COLLEGE INDEMNITY AND DAMAGES, RULES AND REGULATIONS AND RIGHTS
(Continued)
OrganizationisrequiredtoadheretoCollegepolicies,regulations,guidelinesandalllocal,stateandfederallawsregarding
healthandsafety.FailuretocomplywiththeseregulationsmayresultinforfeitureoftheprivilegeofusingCollegefacilities
andservices.Organizationherebywaivesanyclaimfordamagesorcompensationresultingfromsuchforfeitureofprivilege.
CollegeregulationsincludebutarenotlimitedtothefollowinginCollegeHousingandonCollegeProperty:
A. Residence Hall Property: Housing property, in particular furniture, may not be removed from the rooms, lounges or
laundryroomwithoutconsentoftheToddWehrCenterManager.
B. QuietHours/CourtesyHours:Courtesyhoursareineffect24hoursaday.Considerationofotherguestsandorsummer
schoolresidentsisrequired.(i.e.Noloudplayingofmusic,etc.)
C. Dismissal Offenses: Offenses which may lead to dismissal with no refund include but are not limited to: Conduct or
behaviorthreateningthesafetyorwellbeingofothers;misusingortamperingwithfireequipment;intentionaldamage,
theft or destruction of college and/or campus property; the unauthorized discharge of fireworks anywhere on the
Carthage College campus; possessing, using or selling illegal drugs; possessing or using firearms or other weapons
anywhereontheCarthageCollegecampus;andthrowingordroppingofpotentiallydangerousobjectsoutofwindows.
The College shall have the following rights: to enter any room for the purposes of inspection, repair or emergency; to
reassignresidentswithinaresidencehallinordertoaccomplishnecessaryrepairs;andtorevokecampusprivilegestoany
guestwhoseconduct,solelyintheCollege’sopinion,becomesinjuriousorpotentiallyinjurioustothecollegecommunity.
Thereisa$125.00FeefromtheCollegeforlostordamagedkeys.IunderstandthattheOrganizationshall
be responsible for any such charges from the College for lost/damaged keys for any keys issued to the
Organization.
MysignaturebelowatteststhatIamauthorizedtosignthisdocumentasarepresentativeoftheOrganization.
OrganizationDirectororOfficialPrintName:________________________________
DirectororOfficialSignature:_____________________________
Datedthis______dayof____________,2015
10
PACKET ONE (Continued):
(All Section One Documents MUST
be submitted to reserve a team to camp).
SECTION THREE: TEAM REGISTRATION INFO
Section Totals:
X $235.00
Total Number of
Athletes
Cost per Athlete
Total Number
Of
Coaches and
Chaperones
= $
x $110.00
Cost per Coaches/
Chaperones
= $
Grand Total:
TeamGrandTotalforCampRegistration:
TotalAthleteCost/TotalManager/Coach/Chaperone=
$
CheckNumber:_______________________
ONCE THE REGISTRATION IS SUBMITTED TO THE IRCA, ALL
TEAMS WILL BE REQUIRED TO MAKE FULL PAYMENT TO
THE IRCA FOR THE RESERVED SPOT REGARDLESS OF
ATTENDANCE OR NOT.
A Deposit of 50% is due by April 1 2015.
Final Payment is due May 8, 2015.
IN ORDER TO RESERVE YOUR TEAMS REGISTRATION, ALL PACKET ONE PAGES (pages 7 - 10) MUST BE
SCANNED/SENT OR FAXED TO THE IRCA—ONCE RECEIVED, YOU WILL RECEIVE A CONFIRMATORY
MESSAGE ACKNOWLEDGING ACCEPTANCE BY THE IRCA.
Scanned documents: [email protected] / Fax: (847) 352-1961
11
PACKET TWO
All Items must be received into the IRCA by May 8, 2015
How to fill out PACKET TWO::
4). Section Four:
Complete the Team Roster including each athlete’s
name, Birth Date and Shirt Size (For the Free
“White Out/Nite Out” T-shirt. (Athletes Only)
5). Section Five:
Complete the Coach and Chaperone Information
6). Complete the “IRCA Camp Combo Order Form” (Optional).
7). Each Camper (Athletes, Coaches and Chaperones) must complete
the 2015 IRCA “Summer Spirit Camp” Waiver Form
8). Each Camper (including Athletes, Coaches and Chaperones) must
complete the Summer Camp and Conference Overnight
Registration Form and Health Form from Carthage College.
9). Make payment (check or money order) payable to IRCA. A Deposit
of 50% is due April 1, 2015. Final Payment is due May 8, 2015 No
refunds will be given.
10). Mail completed packet to:
Illinois Recreational Cheerleading Association
Attn: IRCA Summer Spirit Camp
610 Estes Ave.
Schaumburg, IL 60193
12
PACKET TWO
All Items must be received into the IRCA by May 8, 2015
Please list room pairings below — Two Campers per room.
ATHLETE NAME
Age
Birth date
Shirt Size (Circle One)
1
YS YM YL AS AM AL AXL
2
YS YM YL AS AM AL AXL
3
YS YM YL AS AM AL AXL
4
YS YM YL AS AM AL AXL
5
YS YM YL AS AM AL AXL
6
YS YM YL AS AM AL AXL
7
YS YM YL AS AM AL AXL
8
YS YM YL AS AM AL AXL
9
YS YM YL AS AM AL AXL
10
YS YM YL AS AM AL AXL
11
YS YM YL AS AM AL AXL
12
YS YM YL AS AM AL AXL
13
YS YM YL AS AM AL AXL
14
YS YM YL AS AM AL AXL
15
YS YM YL AS AM AL AXL
16
YS YM YL AS AM AL AXL
17
YS YM YL AS AM AL AXL
18
YS YM YL AS AM AL AXL
19
YS YM YL AS AM AL AXL
20
YS YM YL AS AM AL AXL
21
YS YM YL AS AM AL AXL
22
YS YM YL AS AM AL AXL
23
YS YM YL AS AM AL AXL
24
YS YM YL AS AM AL AXL
25
YS YM YL AS AM AL AXL
26
YS YM YL AS AM AL AXL
Athlete registration continues on next page.
13
PACKET TWO
All Items must be received into the IRCA by May 8, 2015
Athlete registration continues
ATHLETE NAME
Age
Birth date
Shirt Size (Circle One)
27
YS YM YL AS AM AL AXL
28
YS YM YL AS AM AL AXL
29
YS YM YL AS AM AL AXL
30
YS YM YL AS AM AL AXL
31
YS YM YL AS AM AL AXL
32
YS YM YL AS AM AL AXL
33
YS YM YL AS AM AL AXL
34
YS YM YL AS AM AL AXL
35
YS YM YL AS AM AL AXL
36
YS YM YL AS AM AL AXL
SECTION FIVE: COACH/CHAPERONE INFORMATION
NAME
Over 21 y/o?
CIRCLE ONE
1
YES/NO
COACH
CHAPERONE
2
YES/NO
COACH
CHAPERONE
3
YES/NO
COACH
CHAPERONE
4
YES/NO
COACH
CHAPERONE
5
YES/NO
COACH
CHAPERONE
6
YES/NO
COACH
CHAPERONE
7
YES/NO
COACH
CHAPERONE
8
YES/NO
COACH
CHAPERONE
9
YES/NO
COACH
CHAPERONE
10 YES/NO
COACH
CHAPERONE
14
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DO NOT TAPE OR STAPLE TOGETHER
Illinois Recreational Cheerleading Association
2015 “Summer Spirit Camp” Waiver Form
MEDICAL RELEASE FORM
(Completed for each participant PRIOR TO PARTICIPATING)
ORGANIZATION NAME:
GRADE LEVEL OF
ATHLETE (circle please):
6
7
8
H.S.
PARTICIPANT INFORMATION:
PARTICIPANT NAME:
HOME PHONE:
BIRTH DATE:
MAILING ADDRESS:
CITY:
STATE:
ZIP:
E-MAIL ADDRESS:
EMERGENCY CONTACT:
PHONE NUMBER:
Release of Medical and Personal Information and Statement of Waiver
I, a parent or legal guardian of minor, authorize the Illinois Recreational Cheerleading Association (IRCA), American
Recreational Cheerleading and Redlok Productions, Inc. to copy and distribute this document in any format they so
choose, including but not limited to, paper, electronic and/or facsimile transmission to all events for the 2015 season as
listed on page one of this document. My signature on this document represents that I agree to the release of my minor’s
personal and health information along with my personal information and I waive my rights to any and all actions against
the Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Redlok Productions,
Inc., ACE Cheer Camps, d/b/a North Shore Athletics, Inc., Jeffrey Siegal, Justin Boumstein and all employees and
instructors of the above, for losses or damages which may be suffered by the minor or the undersigned in connection
with such release including any injury, loss or damage arising by reason of the negligence, or alleged negligence,
including willful and wanton negligence, of the Illinois Recreational Cheerleading Association (IRCA), American
Recreational Cheerleading, Redlok Productions, Inc., ACE Cheer Camps, d/b/a North Shore Athletics, Inc., Jeffrey
Siegal, Justin Boumstein and all employees and instructors of the above.
I, the parent or legal guardian of the below named minor, do hereby give my consent to his/her participation in all
activities of the Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading and Redlok
Productions, Inc., and ACE Cheer Camps, d/b/a North Shore Athletics, Inc., as outlined in this document. In case of any
illness or injury to my minor resulting from participation, I hereby waive any and all claims against the organization,
sponsors, supervisors, managers, employees, instructors, owners or Board Members and hereby release, discharge, hold
harmless and indemnify the Illinois Recreational Cheerleading Association (IRCA), American Recreational
Cheerleading, Redlok Productions, Inc., and ACE Cheer Camps, d/b/a North Shore Athletics, Inc., Jeffrey Siegal and
Justin Boumstein, for any and all claims, demands, damages or rights of action against them and agree not to sue the
Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Redlok Productions, Inc.,
ACE Cheer Camps, d/b/a North Shore Athletics, Inc., Jeffrey Siegal and Justin Boumstein, or any of its officers or
employees for any injury, loss or damage which may be suffered by the undersigned or minor of the undersigned in
connection with such activities, including any injury, loss or damage arising by reason of the
DO NOT TAPE OR STAPLE TOGETHER
DO NOT TAPE OR STAPLE TOGETHER
Illinois Recreational Cheerleading Association
2015 Medical Release Waiver
Page 2
negligence, or alleged negligence, including willful and wanton negligence, of the Illinois Recreational Cheerleading
Association (IRCA), American Recreational Cheerleading, Redlok Productions, Inc. or any such official or employee(s)
of the Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading and Redlok
Productions, Inc., and ACE Cheer Camps, d/b/a North Shore Athletics, Inc., Jeffrey Siegal and Justin Boumstein. In the
event of an emergency situation relating to my minor listed below, and in the event that I am unavailable, I hereby give
consent to allow Emergency Medical Technician(s), Athletic Trainers or any medical institution to administer whatever
such emergency medical care is deemed appropriate by the emergency medical staff until I can be contacted.
I, the undersigned, give my consent for photographs or videos to be taken of myself or my minor at any activities of the
Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading and Redlok Productions,
Inc., for publication in promotional or marketing material, web site, or any other uses the Illinois Recreational
Cheerleading Association (IRCA), American Recreational Cheerleading and Redlok Productions, Inc. deem necessary. I
further agree that I consent to the use of said photographs or video without right to compensation of any type or form,
that I do not expect any monetary payment or any other consideration, and that I do not have any right to any monetary
payment or any other consideration. I, the undersigned, also agree that my personal information may be used for
communications, including but not limited to, information regarding competitions and events, marketing and/or
promotional materials, from the Illinois Recreational Cheerleading Association (IRCA), American Recreational
Cheerleading and Redlok Productions, Inc. and/or their affiliates. I also understand that I may opt out of such
communications at any time by contacting the Illinois Recreational Cheerleading Association (IRCA).
By signing below, I, a parent or legal guardian of the below named minor, hereby indicate that I have read this document
and agree to any and all such terms contained herein.
CHEERLEADER NAME: _____________________________________________
ORGANIZATION NAME: _____________________________________________
_________________________________
(Please Print) Parent or Legal Guardian Name
________________________________
Signature of Parent or Legal Guardian
_________________________________
Date
DO NOT TAPE OR STAPLE TOGETHER
DO NOT TAPE OR STAPLE TOGETHER
Athletico Waiver of Liability
I, parent or legal guardian of below named child, consent to have an Athletico, Ltd. athletic trainer or
associate personnel provide my child with first-aid assistance and/or treatment and agree to save and hold
harmless, indemnify and release Athletico, its officers, agents and employees, including Athletico’s athletic
trainer, from and against any and all liability, suits, loss, cost and expenses including but not limited to
reasonable attorney’s fees and court costs, claims of damage whatsoever, including death or damage to
property caused by or as a result of any act or omission of Athletico, its staff, and any other of its agents or
employees.
CHEERLEADER NAME: _____________________________________________
_________________________________
(Please Print) Parent or Legal Guardian Name
________________________________
Signature of Parent or Legal Guardian
_________________________________
Date
DO NOT TAPE OR STAPLE TOGETHER
Summer Camp and Conference Overnight
Registration Form and Health Form
*This form must be completed before campers can participate in any events at Carthage
College*
Camp/Conference Name:
Date of Camp:
Last Name:
to
First Name:
Home Address:
(Street)
Home Telephone Number: (
(City)
)
(State)
(Zip)
Date of Birth:
(Month, Day, Year)
E-mail:
Sex:
Male
Female
Check One:
Camper
Relationship:
Emergency Contact:
Home Telephone: (
Cell Phone: (
Adult Leader/Chaperone
)
Work Telephone: (
)
)
Address:
(Street)
City
State
Zip
CONSENT FOR MEDICATION ADMINISTRATION AND MEDICAL
TREATMENT
Parents or Legal Guardian:
If your son, daughter, or ward will be under the age of 18 while at Carthage College, it is camp
policy to secure your consent for medication distribution and for the use of medical devices. The
medication or medical device can be self-administered or be administer by designate camp health
staff with the exception that controlled drugs (i.e. Codeine, Ritalin, Adderall, Dexedrine, etc.)
must, by law, be administered by camp health staff.
All prescription medication must be in the original medicine bottle and labeled with the camper’s
name, doctor’s name, medication name, dosage, prescription number, date prescribed, and
instructions. You must also complete the form below:
No medication(s) have been brought to camp.
I want the medication or medical devices self-administered (age 14 or above only).
I want the medication or medical device administered by the designated camp staff.
However, a limited amount of medication for life-threatening conditions may be carried by my
son/daughter/ward (i.e. bee sting kit, inhaler, insulin syringe).
If your son, daughter, or ward will be under the age of 18 years while at camp, it is the policy to
secure your consent for all of the following. By signing below,
- I am giving my consent in advance for medical treatment at an appropriate medical
facility in case of illness or injury.
- I am stating that I am aware of and accept the risk inherent in the program activity
- I attest that all information on this form is correct.
- I agree to hold harmless and indemnify the Board of Trustees of Carthage College,
their officers, agents, and employees for any and all liability, loss, damages, costs, or
expenses which are sustained, incurred, or required arising out of the actions of my
son, daughter, or ward in the course of the camp/event.
Date of last Tetanus Booster:
Medications Camper will be taking at camp:
Name of
Medication
Reason
Dosage (mg)
Time of day
given
Prescribing
Physician &
Phone Number
Health Conditions (Check)
specifics)
Allergies (check & list
O
O
O
O
O
O
O
O
Asthma__________
Diabetes__________
Epilepsy__________
Other Conditions
Signature of Parent or Legal Guardian
Insect stings
Foods
Medications
Other Allergies
Date