Participant Packet
ArtSea
Spring 2016
This packet includes forms for your childs participation in our
ArtSea Series. All forms indicated by * are REQUIRED for
participation.
1. Release of Liability Form*
2. Code of Conduct*
3. Emergency Form*
4. Participant Information Sheet
ASSUMPTION OF RISK, RELEASE OF LIABILITY, WAIVER OF CLAIMS, PHOTO
& MEDIA RELEASE AND INDEMNITY AGREEMENT FOR UNCW PROGRAM
In consideration of (student’s name)
being allowed to
participate in the ArtSea (hereinafter referred to as the ‘Program’), as his/her custodial parent/guardian, I hereby
agree as follows:
I do hereby affirm and acknowledge that I have been fully informed of the inherent hazards and risks to my
child, including risks that can occur when participating in any on/near the water based activities, associated with
classroom activity, field activities and game playing, including property damage, falls, contact with other
participants, sprains, and other personal injury, I voluntarily authorize my child’s participation in reliance upon my
own judgment and knowledge of my child’s experience and capabilities.
I give permission to any doctor, hospital, or other medical agency to release confidentially to the treating
physician(s) for my child any information they may have concerning his/her medical condition and their
professional contact with him/her. I hereby grant my permission for such diagnostic, therapeutic, and operative
procedures as may be deemed necessary for my child. (Where practical, you will be notified by telephone before
any procedures are done.) A photocopy of this permission is to be considered as valid as the original. I further
understand that treatment for any medical problems my child may suffer is my responsibility and will be paid by me
and/or covered by my insurance.
I shall indemnify, defend and save harmless UNCW, its officers, directors, employees, representatives,
agents and volunteers from all liabilities, losses, costs, damages, claims or causes of action of any kind or nature
whatsoever, and expenses, including attorneys fees, arising or claimed to have arisen out of personal injuries or
death, or property damage or loss, sustained by my child or me as a result of negligence on the part of any of the
entities or individuals identified above as a result of my child’s own negligence or intentional acts, during my child’s
participation in this Program, including travel to and from the activity sites.
I have agreed that my child may be photographed, audio or videotaped by the Program or UNCW. With my
signature, I agree that photographic image(s) and information that correspond with the photographic image(s) may
be disseminated for any public release usage by the Program or UNCW.
□ Check only if: I do not agree to photo/media dissemination for any public release from UNCW
I understand that this is a legal document which is binding on me, my heirs and assigns and on those who
may claim by or through me. I am eighteen years of age or older, have full capacity to enter into this Agreement,
and do so voluntarily.
THIS IS A RELEASE OF LEGAL RIGHTS, READ CAREFULLY BEFORE SIGNING.
MY SIGNATURE BELOW ACKNOWLEGES THAT I HAVE READ THIS AGREEMENT, I
UNDERSTAND IT AND I AGREE TO BE BOUND BY IT.
Parent’s/Guardian’s Signature
Parent’s/Guardian’s Printed Name
(Signature of one parent binds both parents)
Student’s Printed Name
Date
MarineQuest Participant Code of Conduct
To ensure that everyone has a positive experience while participating in a program located at facilities of the
University of North Carolina Wilmington (“UNCW”), students attending the Program are expected to behave in a
disciplined, responsible, and respectful manner when on or off the UNCW campus. Failure to follow these rules and
regulations will subject the campers to immediate disciplinary action as described more fully below.
As a condition of the Student’s participation, both Parents and Students must agree that neither UNCW (nor the
instructors, staff members, resident assistants and desk staff) are guarantors of the safety of the Students,
particularly for the Students’ unsupervised time, and instances where the Students fail to follow applicable rules
and regulations.
Parents, please read these rules (with your child), sign the bottom, and return the form.
Students will:
-
respect Program staff requests and follow all of their directions with a positive attitude;
respect all safety guidelines required by Program staff and UNCW;
wear appropriate clothing and closed-toes shoes during all field activities;
respect the differences in other people, make an effort to include everyone, and not behave in a manner
that may hurt another camper or staff member’s feelings;
pick-up after myself (at all locations including bathrooms) and throw all trash away;
respect other people’s personal property;
treat all animals (invertebrate and vertebrate) and their environments with respect;
respect all UNCW property including equipment, boats, buildings and the campus;
be respectful of UNCW students and staff when in university buildings;
let my Program counselor know if I am not having a good time;
immediately bring disagreements to the attention of Program staff;
behave in an age-appropriate manner and have fun while remaining safe to others and myself;
Students will not:
-
fight with other participants using any part of their body, gestures or words;
go anywhere without the permission and accompaniment of instructors;
go into water above knee-level unless given permission while in a lifeguard’s presence
use derogatory terms or offensive language at any time;
tease or bully other participants;
bring inappropriate items to programs (weapons, drugs, cigarettes, R-rated materials, etc)
bring electronic equipment [if you chose to bring a cell phone, it must be on silent and remain put
away in your backpack during the program; MarineQuest will not be responsible for any water related
or other damage(s) that may occur]
Parents will not:
-
interact with Program staff in a threatening/abusive manner at any time (in person or on the phone) or
they will risk their child’s dismissal from the Program without tuition/fee refund.
interact with other parents in a threatening/abusive manner while attending the program or on site
I acknowledge (with my signature below) that if the Student Code of Conduct is not adhered to by myself or my
child:
First offense – student will be given a verbal warning explaining the expected behavior (unless the offense involves
a violation of the MarineQuest Zero Tolerance Policy for which student will be immediately dismissed)
Second offense - student will be removed from the activity and my parent(s) will be called to discuss my behavior.
Third offense – student’s parent(s) will be called notifying them of my dismissal from program.
Additional information about the MarineQuest Zero Tolerance Policy can be requested by calling 910-962-2640.
Parent’s/Guardian’s Signature
Date
Student’s Signature
Date
(student signature is required to acknowledge they have reviewed Code of Conduct with parent and will adhere to it)
MARINEQUEST PARTICIPANT INFOMRATION AND MEDICAL
RELEASE FORM
Program Registering for
Date of Program
Name of Participant
Male
Female
Date of Birth: ________/________/_______
Custodial Parent/Guardian Name (if applicable)
Home Address
City
State ________
Day Phone (______)
Zip
Evening Phone (______)
Parent/Guardian e-mail (print clearly)
Alternate Emergency Contacts:
Primary (Name)
Relationship to participant
Phone # (
)
Secondary (Name)
Relationship to participant
Phone # (
)
(1) If you plan on carpooling or (2) the student must leave the program for any reason and you cannot be
reached, there must be another adult available who will take responsibility for removing the student from campus.
Name(s) of adult(s) other than parent/guardian authorized to act on your behalf in this situation:
Name
Phone #(s)(
)
Name
Phone #(s)(
)
Phone #(s)(
)
Physician or clinic you usually consult for medical care:
Name
Medical Insurance Information
Do you have medical insurance coverage for the participating student?
Yes
No
If yes, complete the following information:
Insurance Company’s Name
Medical/Hospitalization Insurance Policy #
Phone Number of Office Holding Policy (
Medical Information:
)
Date of last tetanus immunization (required info)
/
/
Allergies:
Current medical/behavioral/psychological problems being treated
Current restrictions/recommendations due to medical condition(s)
Is an identification band or card carried to alert others to the allergy(ies), medical conditions or medication use?
Yes
No (check one)
Participant Important Information
ArtSea programs include indoor and outdoor activities; therefore with the highly variable nature of
Wilmington weather we ask that you check the weather forecast and dress your child accordingly.
Occasionally, we will experience unexpected cold fronts, so a jacket/coat and pants should be included in
your packing list. Please bring a healthy snack and a water bottle - the MarineQuest staff will provide
access to water for refills during program times. Please note that MarineQuest activities are rain or shine. If
weather becomes too poor to participate in scheduled outdoor activities MarineQuest will move the
program indoors.
Make Sure You Wear/Bring:
□ Clothes that can get wet / dirty
□ Closed-toed field shoes
 NOT sandals, TEVAs or Crocs
□ Hat with a visor
□ Jacket/sweatshirt/windbreaker/coat
□ Backpack containing:
□ Water bottle(s)
□ Snack (no peanuts please)
□ Raincoat
□ Any medications