Lead the Pack 2016 Registration and Health Form
Name: ___________________________________________
Phone Number:
Birth date: ________/_______/_________
Sex: Male _____ Female _____ Student ID:
Home address:
Street
City
State
Zip
Please check the session you have registered for:
 Session I – July 31-Aug. 2, 2016
 Session II – Aug. 7-9, 2016
 Session III – Aug. 9-11, 2016
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:
Relationship to camper:
Address:
Phone number: Home:
Work:
Email address:
Fax:
SECONDARY EMERGENCY CONTACT
Name:
Relationship to camper:
Phone number: Home:
Work:
Agreement for Assumption of Risk, Indemnification, Release, and Consent for Emergency Treatment
I,
agree to participate voluntarily in the Lead the Pack program at the Central
Wisconsin Environmental Station (CWES) at the University of Wisconsin - Stevens Point.
I understand that I am being asked to read reach of the following paragraphs carefully. I understand that if I wish to
discuss any of the terms contained in this agreement, I may contact Tom Quinn CWES Director at 715-346-2705 or Jeff
Karcher, UW-Stevens Point Director of Safety & Loss Control at 715-346-3901
CONSENT FOR EMERGENCY TREATMENT
While the Central Wisconsin Environmental Station (CWES) has operated with an excellent safety and health record since
opening in 1975, illness and injuries sometimes occur. Should a medical emergency occur, we will notify you immediately. If
we are unable to reach you and your child needs medical attention, your child will be transported to the Aspirus Clinic in Plover
Wisconsin or Saint Michael’s Hospital Emergency Room in Stevens Point and treated by the physician on duty.
I authorize the University of Wisconsin-Stevens Point and its designated representatives to consent, on my behalf, to any
emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. In the event that I
cannot be reached, I give permission to the physician selected by the Central Wisconsin Environmental Station to secure and
administer proper medical treatment, hospitalize, order injection, anesthesia, or surgery for the participant. I agree to be
responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
Participant signature
Date:
Also Guardian if participant is under 18
Date
ASSUMPTION OF RISKS
I understand that physical activity related to CWES camps and programs, by their very nature, carry certain inherent risks that
cannot be completely eliminated regardless of the care taken to avoid injuries. Activities may include hiking, climbing, fishing,
swimming, game playing, boating/canoeing, campfire gathering, archery, horseback riding, ropes course, fieldtrips and other
camping activities (refer to your specific camp description for details). The specific risks vary from one activity to another, but
in each activity the risks may range from: 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as
fractures, internal injuries, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis
and death. I understand that the University has advised me to seek the advice of a physician before allowing participation by
my child/ward. I understand that I have been advised to have health and accident insurance in effect and that no such coverage
is provided for my child or ward by the University or the State of Wisconsin. I know, understand, and appreciate the risks that
are inherent in the above-listed programs and activities. I hereby assert that my participation is voluntary and that I knowingly
assume all such risks.
Participant signature
Date:
Also Guardian if participant is under 18
Date
HOLD HARMLESS, INDEMNITY AND RELEASE
In consideration of permission for me to voluntarily participate in CWES camps and/or programs, today and on all future dates,
I, for myself, child/ward my heirs, personal representatives or assigns, agree to defend, hold harmless, indemnify and release the
Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stevens Point, and their officers,
employees, agents, and volunteers, from and against any and all claims, demands, actions, or causes of action of any sort on
account of damage to personal property, or personal injury, or death which may result from my participation in the above-listed
program. This release includes claims based on the negligence of the Board of Regents of the University of Wisconsin System,
the University of Wisconsin-Stevens Point, and their officers, employees, agents, and volunteers, but expressly does not include
claims based on their reckless and intentional misconduct or gross negligence. I understand that by agreeing to this clause I am
releasing claims and giving up substantial rights, including my right to sue. I also agree to reimburse the Central Wisconsin
Environmental Station for any expense incurred for any medical treatment received by my child/ward while participating. In the
event of major medical treatment, Saint Michael’s Hospital or other medical facility will contact you regarding payment.
Participant signature
Date:
Also Guardian if participant is under 18
Date
PHOTOGRAPHIC/VIDEO RELEASE
I understand that the University of Wisconsin-Stevens Point and the Central Wisconsin Environmental Station may take
photographs and/or videos of camp participants and activities. I agree that the University of Wisconsin-Stevens Point shall be
the owner and may use such photos and/or videos relating to the promotion of future camps and programs. I relinquish all rights
that I may claim in relation to the use of said photographs and/or videos.
Participant signature
Date:
Also Guardian if participant is under 18
Date
PARTICIPANT HEALTH HISTORY
Name:____________________________ Birthdate:__________ Age:______
Consent for medication administration and treatment:
 Male
 Female
All prescription medication you bring to Lead the Pack must be in the original medicine bottle (see picture at right) and labeled with
your name, doctor’s name, medication name, dosage, prescription number, date prescribed, and instructions. We need to know what
medications you bring to this program in case you would have an allergic reaction. Please indicate below what you would like to do
with your medication(s).

No medication(s) has been brought to CWES.

I will self-administer the medication or medical devices (age 18 and above only).

I want the medication or medical device administered by the designated CWES staff member.
However, a limited amount of medication for life-threatening conditions may be carried by me (i.e. bee
sting kit, inhaler, insulin syringe).
Medications you will be taking at camp (attach additional pages if needed):
Name of Medication
Reason
Dosage (mg)
Times of day given
Prescribing physician and phone number
Health Conditions (check all that apply to the participant and explain below, including severity)
 Sleepwalking
 Bed-wetting
 Athlete’s foot
 Warts
 Eating Disorder
 Diarrhea/Constipation
 Abnormal Menstration
 Homesickness
 Does NOT swim (describe)
 Nightmares
 Exercise Induced Difficulties
 Frequent Ear Infections
 Heart Defect/Disease
 High Blood Pressure
 Diabetes
 Frequent Headaches
 Indigestion
 Sinus Trouble
 Frequent Nose Bleeds
 Bleeding/Clotting Disorder
 Fainting/Dizziness
 Emotional/Behavioral Disorder
 Skin Problems
 Bone/Joint Problems
 Head/Neck/Back Injuries
 Epilepsy/Convulsions/Seizures
 Visual Impairment/Glasses...
 Hearing Impairment/Aids
 Speech Impairment
 Learning Disability
 ADD or ADHD
 Cognitive Disability
 Chronic Illness/Condition
 Cerebral Palsy/Motor
 Picky Eater
 Vegetarian
 Vegan
 Gluten Free
 Allergies
 Asthma
 Contagious Disease(s)-List
 Other
Give details including triggers, signs/symptoms, care procedures, side effects of medications:
ALLERGIES: Please list and describe any participant allergies to medications, food, insects, animals, plants, etc…
Medications:
Foods:
Insects/Animals/Plants/etc.
RESTRICTIONS: List and describe any restrictions, limitations, or other conditions including: recent
injury/illness/infection, Dietary, Health Conditions (physical, behavioral, emotional, mental), Impairments, Other
Illnesses, Major Surgeries, Special Needs, Family Conditions and indicate if there are any adaptations that can be made:
Name of Insurance Co.:
Insurance Co. Phone #
Family Physician and/or medical facility:
Policy #:
Holder:
Phone Number:
I hereby state that the information I have provided is accurate and complete. I understand that it is my
responsibility to provide any changes/updates to CWES. I further understand that my failure to provide
accurate, complete, and updated information may jeopardize participation in this program. If participant has
NOT been fully immunized – I understand and accept the risks from not being fully immunized.
Participant signature
Date:
Also Guardian if participant is under 18
Date