UCI ATHLETICS
One form per child
Print legibly, Blue or Black Ink Only
CAMPS & COMMUNITY PROGRAMS REGISTRATION FORM
REGISTER ONLINE AT WWW.UCIRVINESPORTS.COM
CONTACT INFORMATION: PHONE: 949-824-6120 FAX: 949-824-5030 EMAIL: CAMPS@UCI.EDU
PERSONAL INFORMATION
Participant’s Name: ______________________________________________Age: _______Date of Birth: ____/____/_____Gender: M
First
F
Last
Address: ___________________________________________________________________________________________________________
Zip
State
Mother/Guardian:___________________________________________________________________
Street
Day
CityPhone
Name
Junior Anteater Club
Father/Guardian:____________________________________________________________________
Name
Day Phone
School:___________________________________Grade(2014-2015):_______E-Mail_______________________________________________
(REQUIRED: confirmation information sent via e-mail)
Day Phone
Meal Options : No Preference
Veggie
T-Shirt Size: Youth: M
(Full Day, Advanced, Elite, Overnight Camps)
L
Adult: S
M
L
XL
(For FULL DAY, ELITE, COMMUTER, & RESIDENTIAL CAMPS)
Overnight Camps Only- Camp Type: Residential
Commuter
Roommate Preference:____________________________________
How did you hear about our camps?:____________________________________________________
CAMP INFORMATION (Please list all camps registering for present and future)
If lunch is not included in fee, please write “W/Lunch” after camp name if you wish to purchase. Lunch cannot be purchased during walk-up registration
CAMP NAME
PAYMENT METHOD: CHECK
FULL OR HALF DAY
DATES
FEES (Staff Use)
TOTAL PAID $
CREDIT CARD
MEDICAL INFORMATION & CONSENT
I (we) the undersigned parent(s), or legal guardian of (Name of Child)___________________________, do hereby request that he/she be permitted to attend the UC Irvine
Summer Camps and should the need arise do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis and treatment rendered under the
supervision of licensed physician. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to
provide authority and power to render care which the licensed physician in the exercise of his/her best judgment may deem advisable.
It is understood that, if possible, effort shall be made to contact the undersigned prior to rendering treatment but that of any of the above treatments will not be withheld if the
undersigned cannot be reached in a timely manner. I (We) will not hold liable the Regents of the University of California, its officers, employees, or agents for medical aid rendered
and will be solely responsible for all medical or other expenses incurred in the care of my child.
I authorize release of the information on this form to any licensed physician, hospital or medical staff member involved in the treatment or care of my child.
Emergency Contact____________________________________________________
Phone:_______________________________
Medical History (Allergies, injuries, etc):____________________________________ Current Medications:___________________________
Insurance Name:__________________________ Policy #:____________________ Holder name:___________________________
(REQUIRED, If none, mark NA)
I am the parent or legal guardian of __________________________ and I have read, understood and agree to the
terms and conditions of this application and I am signing this release on behalf of said minor.
PARENT/GUARDIAN SIGNATURE: ______________________________________
DATE:___________________
WAIVER AND RELEASE FROM LIABILITY
UNIVERSITY OF CALIFORNIA, IRVINE
DEPARTMENT OF INTERCOLLEGIATE ATHLETICS
(to be completed by participant)
Subject:
I recognize and expressly agree that participating in any sport or activity associated with athletics is an inherently dangerous activity.
Further, I recognize that certain safety precautions must be followed, yet even strict adherence to those procedures does not guarantee
nor does UC Irvine Athletics guarantee Participant’s Safety.
Waiver and Release from Liability:
In consideration of permission to use, today and on all future dates, the property, facilities, staff, equipment and services of UC IRVINE
ATHLETICS, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The
Regents of the University of California, its directors, officers, employees, and agents from liability from any and all claims including the
negligence of UC IRVINE ATHLETICS, resulting in personal injury, accidents or illnesses (including death), and property loss arising from,
but not limited to, participation in activities, classes, observation, and use of facilities, premises, or equipment.
Assumption of Risks:
Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid
injuries. UC IRVINE ATHLETICS, have facilities for and provides for activities such as weight lifting, running, aerobic activities, classes and
sporting activities. Some of these involve strenuous exertions of strength using various muscle groups, some involve quick movements
involving speed and change of direction, and others involve sustained physical activity which places stress on the cardiovascular system.
The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2)
major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including
paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the activities
made possible by UC IRVINE ATHLETICS. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
Publicity:
I understand that on occasion, UC Irvine Athletics takes photographs or makes audio or video tape recording of children and/or adults
involved in camp activities. Such photographs and audio/visual recordings may be used in the UC Irvine Athletics camp publications,
promotional materials and pertinent website. I understand that such contemplated photos will have no addresses or identifications of
any sort on such photos and are considered the property of UC Irvine Athletics and may not be sold or reused. I agree to the use of any
such audio or visual recording to be used, distributed as administrators of UC Irvine Athletics see fit. This consent includes but is not
limited to: photographs videotape, and audio recordings.
Indemnification and Hold Harmless:
I also agree to INDEMNIFY AND HOLD The Regents of the University of California, HARMLESS from any and all claims, actions, suits,
procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement at UC IRVINE, and
to reimburse them for any such expenses incurred.
Severability:
The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and
inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance
shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding:
I have read this Waiver and Release of Liability and fully understand its terms, and understand that I am giving up substantial rights,
including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a
complete and unconditional release of all liability to the greatest extent allowed by law.
X _____________________________________________________________________
Signature of Parent/ Guardian of Minor
Date
_______________________________________________________________________
Name of Participant