Recreation Sports Activity and Learning Camp Registration Form Name_______________________________________________________ Date____/____/____ Last First MI Birth Date: Sex: Female
Weight: Height: Parent’s Name(s): _______________________________________________________________ Phone #’s Home: ( )_____________ Work: ( )_____________ Cell: ( )_____________ E-­‐Mail Address: _________________________________________________________________ Home Address: _________________________________________________________________ Mailing Address: ________________________________________________________________ IN CASE OF AN EMERGENCY CONTACT THE FOLLOWING PERSONS: Name Phone # Relationship ______________________________________________________________________________ ______________________________________________________________________________ PERSONS (other than parents/legal guardians) listed below may transport my child(ren): Name Phone # Relationship ______________________________________________________________________________ ______________________________________________________________________________ Please list any allergies or medications: (Please Consult with Faculty Nurse concerning Administration of Medication.) ______________________________________________________________________________ Parent’s Signature:___________________________________ Date:_____/_____/_____ Recreation Sports Activity and Learning Camp Medical Emergency Information/ Consent for Treatment Youth’s name: _________________________________________________________________ Address:______________________________________________________________________ Date of birth: ______________ Parent/guardian phone: Home____________________ Work _____________________ Mobile_________________________ E-­‐Mail __________________________________ Medical Information Allergies:______________________________________________________________________ Current medications:_____________________________________________________________ Chronic illnesses (i.e. asthma): _____________________________________________________ Date of last tetanus booster: ________________________________ Physician: ___________________________ Physician telephone number: ______________ Have you been directed to carry an inhaler or breathing device: ________________ HEALTH HISTORY (Check all that apply) ( )Fainting ( )Convulsions ( )Stomach Upsets ( )Asthma ( )Constipation ( )Kidney Trouble ( )Athlete’s foot ( )Rheumatic fever ( )Bronchitis ( )Diabetes ( )Cold ( )Heart Trouble ( )Eye Trouble ( )Ear Infections ( )Allergic Reaction:_________________________ Other:________________________________________________________________________ Explain any restrictions to activity (e.g., what cannot be done, what limitations are necessary) ______________________________________________________________________________ ______________________________________________________________________________ Insurance Information Does youth have health insurance? No _____ Yes____ Medical insurance company: ________________________ Tel. no. _____________________ Group number/ID number: ___________________ Name of insured: ______________________ Person(s) to Notify in Case of Emergency: Name: ____________________________ Relationship:_________________________ Street Address: _________________________________________________________________ Phone: Day_________________ Evening ___________________ Mobile__________________ Second contact (if first person unavailable) Name: ____________________________ Relationship:_________________________ Phone: Day_________________ Evening ____________________ Mobile _________________ Consent for Medical Treatment: The attending physician, appropriate staff, Prairie A&M University, the Texas A&M University System, their Board of Regents, officers, employees, representatives and/or agents, and their heirs, successors, and assigns, shall not be responsible in any way for any consequence from diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability. Prairie View A&M University does not carry medical insurance for participants in any of its programs. It is recommended that you have appropriate medical coverage for your child. I, as parent/legal guardian, grant permission for my child _________________________ to receive medical treatment. X____________________________________________ ____________________________ Signature of parent/legal guardian Date Name of Camper: _______________________________________________________________ Please include the names of those individuals in the space below that you approve to pick up your camper. Parents, guardians, and those approved individuals NEED TO BRING THEIR PHOTO ID to check your camper out. Additions to the approved list can be made by contacting Leah Wallace at (936) 261-­‐9367. *Drop off time: 7:30 A.M. Pick-­‐up time: 5:00 P.M. *An additional charge of $1.00 per minute late for pick up will be assessed to campers remaining on site after the designated 5:00 P.M. pick up time!!! *Drop off/ Pick-­‐up will be conducted at the main desk inside the Student Recreational Center, *Please make certain that you are checking your child in/out at the front desk, BEFORE leaving the facility. Please list the name, and relationship of any approved adult who may pick your child up from camp: Name________________________________________ Relationship____________________ Name________________________________________ Relationship____________________ Name________________________________________ Relationship____________________ I, _______________________, age ____, desire to participate voluntarily in all activities of the PVAMU Recreational Sports Activity and Learning Camp (“Activity”), which is sponsored or conducted by or under the auspices of The Department of Recreational Sports (“Sponsor”), a member of The Texas A&M University System. I am fully aware that there are inherent risks to myself and others involved with the Activity, including but not limited to illness, injury (including death), and loss of personal property, and I choose to voluntarily participate in the Activity and do voluntarily assume the above mentioned risks as to myself and my property, and to the person and property of others. I acknowledge that the Activity may be physically strenuous. I know of no medical reason why I should not participate. CHALLENGE BY CHOICE Challenge course and team-­‐building programs are composed of activities that may be unfamiliar to all participants. To ensure our participants control over their own personal safety, we operate with the philosophy of, “Challenge by Choice.” During the time of child engagement activities, participants are completely in control of their own level of participation. During the program you need only do or attempt to do, only those things that you choose. You must listen carefully to all instructions and briefings, set your own goals free of the influence of the group’s goals, make a decision as to your level of participation and inform others of your choice. No one will force you to do anything; the choice is clearly your own. However, you may receive pressure to push yourself, and we encourage you to tell the group if this happens. During the program, we will provide a challenging setting in which you can expand your limits while supporting your personal boundaries. PVAMU Recreational Sports Activity and Learning Camp CAMP & ENRICHMENT PROGRAM WAIVER, INDEMNIFICATION, AND MEDICAL TREATMENT AUTHORIZATION FORM EXCULPATORY CLAUSE. In consideration for receiving permission for my/my child’s participation in any and all activities of PVAMU Recreational Sports Activity and Learning Camp (herein referred to as “camp”), which is sponsored by the department of Recreational Sports, (herein referred to as “sponsor”), I hereby release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes sponsor, The Texas A&M University System, the Board of Regents for The Texas A&M University System, Prairie View A&M University, and their members, officers, servants, agents, volunteers, or employee (herein referred to as RELEASEES or INDEMNITEES) from any and all liabilities, claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, that may be sustained by me/my child while participating in such activity, while traveling to and from the activity, or while on the premises owned or leased by RELEASEES, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. 1.
INDEMNITY CLAUSE. I am fully aware that there are inherent risks to my child, myself and others involved with this activity, including but not limit to ___________________________________________________, and I choose to voluntarily participate/allow my child to in said activity with full knowledge that the activity may be hazardous to me, my child and my property, and to the person and property of others. I acknowledge there may be physically strenuous activities. I know of no medical reason why I/my child should not participate. I agree to indemnify and hold harmless INDEMNITEES from any and all liabilities claims, demands, injuries (including death), or damages, including court costs and attorney’s fees and expenses, which may occur to myself, my child other participants, and third-­‐persons as a result of my/my child’s participation in said activity, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of INDEMNITEES. 2.
NO INSURANCE. I understand that RELEASEES may or may not maintain any insurance policy covering any circumstance arising from my/my child’s participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. Organization may not carry general liability insurance to cover claims arising from this activity so it seeks a waiver of claims as additional consideration for the right to participate so organization, can (a) provide the activity at the lowest possible cost to participants; and (b) provide access to a greater number of participants by expending limited resources on program materials rather than on liability insurance. 3.
BINDS HEIRS. It is my express intent that this agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am decease, and shall be governed by the laws of the State of Texas. 4.
MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand RELASEES cannot be expected to control all of the risks articulated in this form and RELEASEES may need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at the medical faculty, during my/my child’s participation in this activity with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless INDEMNITEES for any costs incurred to treat me-­‐my child, 5.
TAMUS-­‐ OGC-­‐approved 06/2007 TAMUS-­‐ OGC-­‐approved 06/2007 even if an INDEMNITEE has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes, RELEASEES from any and all liability, claims, demands, injuries (including death), or damages, including court cost and attorney’s fees and expenses, that may be sustained by me/my child while a medical care facility, including injuries sustained as a result of the sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of RELEASEES. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. 6.
VOLUNTARY SIGNATURE. In signing this agreement I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own free act and deed; sponsor has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I execute this document for fill, adequate and complete consideration fully intending to be bound by the same, now and in the future. I understand I can choose not to sign this document and free myself and my child from its terms and the associated risks of the activity by simply not participating in the activity and choosing some other activity available to me/my child that has a lower level of risk to myself and my child. I further understand this is a voluntary, extracurricular activity. While I understand alternative activities are available to me/my child that do not have the risks associated with this activity I still desire to voluntarily engage/permit my child to engage in this activity. SIGNING THIS DOCUMENT INVOLVES THE WAIVER OF VALUABLE LEGAL RIGHTS. CONSULT YOUR ATTORNEY BEFORE SIGNING THIS DOCUMENT. SIGNED this ______________ day of __________________ , 20________ . Participant Signature: __________________________________________________________ Printed Name: _________________________________________________________________ Participant’s Date of Birth:_______________________________________________________ Parent or Legal Guardian Signature:________________________________________________ (If Participant is under 18 years old) 7 Parent or Legal Guardian Printed Name: ___________________________________________ (Participant is under 18 years old) In case of emergency, contact ____________________________________________________________ At the following number: _____________________________________________________________ If the participant has medical insurance, please indicate: Insurance Company: __________________________________________________ Policy Number:_______________________________________________________ Name of Primary Policy Holder: _________________________________________ Please list any special services your child may require: 8