Young Writers’ Camps Registration
Please completely fill out all information, then print and return with payment to the address at
the end of the form.
Camper information
First Name:
Last Name:
Preferred Name:
Date of Birth:
Grade for 2016-17 school year:
Home address:
Email:
Phone number:
School name, city, state:
Parent/guardian info:
Name:
Phone number (where you may be reached during the event):
Email:
Billing Address:
Please select which camp(s) you want to attend and initial the applicable boxes:
☐ C3 Camp: Create, Code, and Compose (in Newberg, June 20-24, 2016, $125)
☐ Camper is a student entering grades 3-5 in 2016-17 school year
☐ Yes ☐ No Camper had coding experience during their third grade year in
Newberg public schools
☐ Oregon Battle of the Books (fully online, July 11-15, 2016, $70)
☐ Camper is student entering grades 7-9 in 2016-17 school year
☐ Camper will have read at least 4 of the 2015-16 OBOB books by the time camp starts
☐ I understand this camp is fully online
☐ Camp Write for a Cause: Acquire Essential Writing Skills While Supporting a Cause (fully
online, July 11-22, 2016, $155)
☐ Camper is student entering grades 9-12 in 2016-17 school year
☐ I understand this camp is fully online
☐ Writing Creative Nonfiction Essays: Featuring College Applications (fully online, July 11-29,
2016)
☐ Camper is student entering grades 10 or 11 in 2016-17 school year
☐ I understand this camp is fully online
☐ Oregon Battle of the Books (fully online, August 1-5, 2016, $70)
☐ Camper is student entering grades 7-9 in 2016-17 school year
☐ Camper will have read at least 4 of the 2015-16 OBOB books by the time camp starts
☐ I understand this camp is fully online
Waiver, Indemnification and Release by Parent or Guardian of Minor Child
Waiver, Indemnification and Release
A) In consideration of participating in any manner in George Fox University Young
Writers Camp, and on behalf of my minor child/children (“child”) identified below, I, the
undersigned parent and natural guardian or legal guardian represent that I am, in fact, acting in
such capacity and agree to the following:
B) I release and hold harmless George Fox University from liability, for or from, any and all
claims, including, but not limited to claims resulting in personal injury, property loss, accidents
or illnesses (including death) arising from participation in George Fox University Young Writers
Camp that I or my child may have, arising from or related to child’s participation in i) any of the
events or activities conducted by or for the benefit of the George Fox University Young Writers
Camps, and ii) while on the premises of George Fox University, or while using George Fox
University-owned or operated facilities or equipment.
C) I do hereby represent that I am, in fact, acting with authority in the capacity of parent and
natural guardian or legal guardian, and I, for myself, my heirs, personal representatives or
assigns, do hereby release, discharge, waive and covenant not to sue, George Fox University, its
board, officers, employees, students, and agents and agree to save, hold harmless, and indemnify
George Fox University from all liability, loss, cost, claim or damage whatsoever which may be
imposed because of any defect in or lack of such capacity to so act.
D) I also agree to indemnify and hold George Fox University, its Board, officers, employees,
students, and agents harmless from any and all claims, actions, suits, procedures, costs, expenses,
damages, and liabilities, including attorney fees brought as a result of my child’s participation in
George Fox University Young Writers Camps, as set forth in paragraph “B)” above, and to
reimburse them for any such expenses incurred.
E) This waiver, indemnification and release agreement applies to any activity or action that takes
place while my child or I are being transported to George Fox University Young Writers Camps,
and is in effect at any time, I, or my child is present on campus or in any location associated with
George Fox University Young Writers Camps.
F) The undersigned further expressly agrees that the foregoing waiver, indemnification and
release agreement is intended to be as broad and inclusive as is permitted by the law of the State
of Oregon and that, if any portion thereof is held invalid, it is agreed that the balance shall,
notwithstanding, continue in full legal force and effect.
Medical Treatment/Emergency Release
If my child is rendered incapable, I grant to George Fox University, its agents or officers, and
any of its personnel full authority to take whatever action they feel is warranted under the
circumstances regarding the participants’ health and safely. George Fox University's personnel
will attempt to seek the direct participation of the undersigned where possible. This authority
will permit the George Fox University representative, or other appointed official of George Fox
University, at their discretion, in the event of injury or illness, to secure any necessary treatment
for my child at any point for medical services, including hospitalization, injections, anesthesia or
surgery and such medications as may be prescribed, when such treatment is recommended by a
qualified physician or surgeon, or, if no hospital is available, to place my child in the hands of a
local medical authority to transport my child at my own expense back to the program’s primary
site for medical treatment if this is deemed necessary by the University personnel, in consultation
with local medical authorities. I and my child agree to hold the University and its representatives
harmless for any decisions or actions taken in relation to obtaining medical care for my child.
Acknowledgment of Understanding and Agreement
I have read this medical treatment/emergency release and waiver, indemnification and release
agreement, 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.
___________________
Initial here
I give permission for my child’s photo and/or comments about the camp to be used by George
Fox University Young Writers Camps, as long as he or she is not identified by name.
___________________
Initial here
Parent/Guardian Information
Signature: _____________________________________________
Print name of adult: _____________________________________
Please print this form and return with payment (check made out to George Fox University) to:
Andrea Byerley
George Fox University
414 N. Meridian #V124
Newberg, OR 97132