Connecting with Culture through Experience
June6ththroughJune10th
9:00am-4:00pm
ThankyouforyourinterestintheIndianPuebloCulturalCentersSummerDayCamp!
Themesforourcampinclude:creativity,thelegacyofPuebloculture,andstewardship.
Wewillexploreandenjoylearningthroughexperiencingindigenoustraditionsinart,gardening,storytelling,
culinaryarts,printmaking,potterymaking,sculpture,painting,illustration,visitstothemuseum,watching
traditionaldance,andmore!
Here’ssomeimportantinformationtoreviewasyouregister:
ImportantInformation:
• OneAdultSession(ages18+)
• WorkshopFeeincludingmaterials:$200.00
ImportantDates:
• Friday,March11th:RegistrationpacketsavailableonlineandattheIndianPuebloCulturalCenter.
• Friday,May20thDeadlineforregistrationpacketsubmission.
Foradditionalinformationandsubmissionofregistrationpacket:
PleasecontactEmmaLeeClarke:eclarke@indianpueblo.org,505-212-7051
IndianPuebloCulturalCenter,240112thStreet,NW,Albuquerque,NM87104
SummerDayCamp
RegistrationPacket
Packetisnotconsideredcompleteforconsideration
unlessallformsareincludedandsigned.
ParticipantInformation:
__________________________________ ________
__________________F___M
ParticipantName
Age DateofBirth Gender
EmailAddress:________________________________Phone#:_________________________
MailingAddress:___________________________________________________ ______________
Address
City
State Zip
Inroughly200words,pleaseshareyourappreciationofPuebloHistory,Art,andCulture
(Useadditionalsheet,ifneeded)
EmergencyContacts
Intheeventofanemergency,contactthefollowing:
PrimaryContact:
Name:__________________________________Relationship:_________________________
Phone1:(______)__________________Phone2:(_____)_____________________________
SecondaryContact:
Name:________________________________Relationship:_____________________________
Phone1:(______)___________________Phone2:(_____)_______________________
ReleaseofLiability
I,_______________________agreetoparticipateintheIndianPuebloCulturalCenter2016SummerAdult
CampfromJune6thtoJune10th,2016.Ihavecarefullyreadthepoliciesforthiscampandunderstandthat
theremaybecertainrisksinvolved.IensurethatIwillfollowallpoliciesandproceduressetforth.Ialso
ensurethatIwillfollowallinstructionsexplainedtomebyprogramleaders,volunteersandinterns,andI
assumeallliabilityformyfailuretofollowinstructions.Iunderstandthattheprograminstructorsmay
immediatelywithdrawmefromtheprogramifIamunableorunwillingtofollowinstructions.
Inconsiderationofmybeingallowedtoparticipateintheprogram,Iwaive,releaseanddischargetheIndian
PuebloCulturalCenter,Inc.IndianPueblosMarketing,Inc.,anditsemployees,agents,representativesand
volunteers,fromanyandallclaims,liabilityanddamagesresultingdirectlyorindirectlyfrommyparticipation
intheprogram,includingbutnotlimitedtothose:1)arisingfrompersonalinjuryand/orpropertydamage
sufferedbymyself,whetherresultingfromthenegligenceorotherconduct,includingallactsandomissions,
oftheIPCC,itsemployees,agents,orvolunteers,theconductofanotherparticipant,theconductofanonparticipant,orfromanyothercause;2)arisingfromthereleaseoruseofmedicalinformationbytheIPCCfor
thepurposesofprovidingmedicaltreatmentforme;3)arisingfromtheprovisionofsuchmedicaltreatment;
and4)foranyandallactionsthatmayberequiredtoprotectmyhealth,safety,andwelfarewhile
participatingintheprogram.
IhavecarefullyreadthisauthorizationandIacknowledgethatIfullyunderstanditscontentsandagreefor
myselftobeboundbyalltermsandconditionssetforththerein.Mysignatureisevidenceofmy
understandingandcommitmenttothisauthorization.
Participantsignature:_________________________________Date:_____________
MedicalAuthorizationForm
SectionI:AuthorizationtoPermitMedicalTreatment
Bysigningbelow,IherebygivepermissiontotheIndianPuebloCulturalCenter,Inc.,IndianPueblos
Marketing,Inc.,itsemployees,volunteersorinterns(collectivelyreferredtoasthe"IPCC")to
providefirstaidforanyinjuriesorillnessesexperiencedbymyself.Iftheinjuryorillnessislifethreateningorrequiresemergencytreatment,IauthorizetheIPCCtoseekmedicalassistanceinthe
eventmyemergencycontactorIisunabletoindicatemywishesregardingtreatment.Iunderstand
thattheIPCCshallnotbeheldresponsibleforthecostsoftreatment.Iherebygrantpermissionto
emergencypersonnel,physiciansandotherlicensedhealthcareprovidersandtheirdesigneesto
attend,transport,andadministermedicalcarethroughinjuryorillnessevaluation,firstaidcareand
referraltodulylicensedmedicalpersonnelwhenindicated.Iwaive,releaseanddischargetheIPCC
fromanyandallclaims,liabilityanddamagesarisingfromtheprovisionofsuchmedicaltreatment.
Pleaseprintallinformation:
Name:_______________________________________________D.O.B.___________________
Address:________________________________________City:_____________________
State:_________________Zipcode_________________
DaytimePhone:(___)_____________Cell:(_____)____________________________
Email:___________________________________________________________________
SectionII:ReleaseofInformation
Iauthorizethereleaseofmedicalinformationbelowtoemergencypersonnelandtreatment
providers,andwillnotholdIPCC/IPMIinanywayresponsibleforthereleaseofthisinformationto
anyemergencypersonnelortreatmentprovider.
Pleaseprintallinformation
Name:_____________________________________________________________
MedicalInsurer/HealthPlan:__________________________________________________
Policy#:_______________________________________
Physician'sName:______________________________Phone#:____________________
ParticipantSignature:_________________________________Date:_________
MedicalHistory
Iftheparticipanttakesanymedications,pleaselistmedicationnameanddosage.Instructors
cannotdispenseprescriptionmedicines.IftheParticipantmusttakeamedicationduringthe
program,she/hemustbeabletotakepersonalresponsibilityforthemedications
HealthHistory
Checkthoseareasthatapply.Providecommentsasnecessary
____Asthma(type:__________________________________________________)
IftheParticipanthasasthma,she/hemustcarrytheasthmamedicationwiththematalltimes.
____Bleeding/ClottingDisorders________________________________________
____Convulsions____________________________________________________
____Diabetes______________________________________________________
____FrequentEarInfections___________________________________________
____HeartDefect/Disease____________________________________________
____Hypertension____________________________________________________
____MusculoskeletalDisorders/Injuries___________________________________
____Seizures____________________________________________
Allergies/AllergicReactions
(Specifyreactionandmanagementofthereaction.)
Ifparticipanthasaknownanaphylacticreaction,she/hemustcarryanEpi-penandanantihistaminewith
thematalltimeswhileoutdoors.
____Animals(animalandreaction)______________________________________
____Food(fooditemandreaction)______________________________________
____HayFever______________________________________________________
____BeeStingsandreaction___________________________________________
____InsectStings(insectandreaction)___________________________________
____Medicines/Drugs(medicine/drugandreaction)______________________________
____Penicillin_____________________________________________________________
____PoisonIvy_____________________________________________________________
____Other(specify)_________________________________________________________
OtherHealthRelatedConditions
___HearingImpairment
___HepatitisType:____________
___GermanMeasles
___Mumps
___Other(specify)____________________
___SpecialDietaryRegimen_______________________________________________
Diseases
ChickenPox______________________________
Measles________________________________
Other(specify)__________________________
AdditionalDocumentation/Comments/Notes:
PleaseprovideanyadditionalinformationthatmaybeusefultotheIPCCinrelationtoanyofthese
healthconditions.Also,indicateanyactivitiestobeencouragedorrestricted.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
PhotoConsentForm
I,______________________herebygrantpermissiontotheIndianPuebloCultural
CentertotakephotoandvideoofmewhileIamenrolledintheIndianPueblo
CulturalCenterSummerAdultCampProgram.Ifurtherunderstandandacknowledge
thatanyphotographorvideotakenbyIndianPuebloCulturalCenterstaffmembers
maybeusedintheIndianPuebloCulturalCenter’snewsletter,website,flyers,
brochures,orfundraisingefforts.IndianPuebloCulturalCentermayshare
photographsandvideoswithparticipants;however,originalnegativesandvideowill
remainthepropertyoftheIndianPuebloCulturalCenter.
____________________________________
ParticipantSignature _____________________
Date