Environmental Science
Academic Programs
UTSA Ecology Summer Camp
2016 Registration Form
Camp Behavior, Policies, and Rules
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Participants must wear appropriate attire and shoes.
For girls:
1. NO short shorts, skirts, bathing suits
2. NO flip-flops. Closed toed shoes ONLY
3. NO spaghetti straps, or tube tops
For boys:
1. NO muscle shirts, or bathing suits
2. NO flip-flops. Closed toed shoes ONLY
3. NO baggy clothing
Good conduct is expected from all participants must remain polite and civil towards the other participants and to
the counselors.
No profanity or fighting will be tolerated in the camp. Disciplinary action for violation of camp rules lie with the
Center Director or Program Manager.
There will be NO misconduct in the University. We are at a university campus and there will be classes in session
during the camps.
There will be NO horse-playing in the camp classrooms. We are using UTSA classrooms and there will be
expensive equipment in the classrooms.
Cell phone usage is not allowed during camp hours, including making phone calls and sending text messages,
unless approved by the counselors.
Electronic gadgets are not allowed during camp hours. Please leave your electronic devices at home.
Day Camp: Participants may be dropped off as early as 7:00 am and pick up as early as 4:00 pm. There will be a
charge of $50 for children picked up from 5:00 pm 6:00 pm. Parents must sign their child in and out daily.
Parents will be contacted if the participant become(s) unruly during camp.
Participants who fail to comply with the camp policies and rules will be dismissed and will not receive a refund.
Furthermore, they will be barred from participating in any future camps held by the Environmental Science
Academic Programs.
Snacks will be provided for all participants. A sack lunch is expected to be provided by parents.
I have read the above policies and will comply with the rules during camp hours.
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Participants’ name
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Signature
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Date
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Print Parent/Guardian name
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Signature
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Date
MEDICAL TREATMENT CONSENT FORM
My son/daughter ___________________________ will be attending UTSA Ecology Summer Camp.
Known Allergies:
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Current
Prescriptions:
Current
Prescriptions:
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Other health information:
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In the event of a medical emergency, an employee of the UTSA Ecology Summer Camp staff has my permission to seek medical
treatment for my child. In an emergency, please call _________________________ (parent/guardian) immediately at:
(
) __________________.
INSURANCE AND HEALTH CARE
Parents should provide health insurance documentation for participants to keep with them during their time at camp. If any camper is
seriously ill or injured, he/she will be accompanied to the closest off-campus medical facility by licensed emergency medical
technicians. Medical costs incurred for treatment will be the responsibility of the parents or guardian of the individual treated.
Individuals with life-threatening conditions will be taken directly to a hospital emergency room. Parental notification of minor injuries
and illnesses is left to the discretion of the camper. Please discuss with your child your expectations regarding communication of such
information. Environmental Science Academic Programs cannot be responsible for or held liable for the administration of medication
to participants. The camper must be able to self-administer his/her own medication. Questions about medical related issues should be
addressed to the Camp Coordinator.
UTSA Photo, Video, Voice, Comment Consent
I am the Parent/Guardian of the above named student who is under 18 years of age and am fully competent to sign this release. I
hereby grant UTSA and Environmental Science Academic Programs the absolute and irrevocable right and permission, with respect to
photographs and videos, voice recordings taken and/or comments made by the above named student or in which student may be
included with others, to copyright for same; to use, reuse and publish the same in whole or in part in any and all media including use
on the world wide web, now or hereafter, and for any purpose whatever for illustration, promotion, art, advertising and trade, and if
appropriate, to use student’s name and pertinent education and/or biographical facts as UTSA and Environmental Science Academic
Programs choose.
I hereby release and discharge UTSA and Environmental Science Academic Programs from any and all claims and demands arising
out of or in connection with the use of photographs, videos and/or commends, including without limitation any and all claims for libel
and invasion of privacy. I have read the foregoing and fully understand its contents. This release shall be binding on me any heirs,
legal representatives and assigns.
(Please check one)
____Has my permission ____Does not have my permission
Parent/Guardian Name (Printed):__________________________________________________________
Parent/Guardian Name (Signed): ________________________________________________________
UTSA RELEASE AND INDEMNIFICATION AGREEMENT FOR PARTICIPANT
Name of Participant
Student Identification Number if
Enrolled at UTSA
Name of Parent/Guardian if
Participant is < 18 years old
Address
Age of Participant
Emergency Contact/Phone Number
Description of Activity/Trip
(including all associated travel)
Location of Activity/Trip
Date of Activity/Trip
UTSA Ecology Summer Camp 2016
MS 3.02.52 (Ecology Lab)
By signing below, I consent to the Participant’s participation in the above-described (“Activity/Trip”) and I certify that
__________________ there is no medical reason why Participant should not participate in the Activity/Trip. I
acknowledge that the nature of the Activity/Trip may expose Participant to hazards or risks that may result in Participant’s
illness, personal injury or death, and I understand and appreciate the nature of such hazards and risks. I understand that
Participant may have unsupervised access to the internet while on the UTSA campus or while otherwise participating in
the Activity/Trip.
Additionally, I understand that __________________ (name of transporter) will transport the Participant during travel to
and from the location listed above and during any additional or incidental travel associated with the Activity/Trip. If the
Participant chooses to drive or to be a passenger in a personally-owned vehicle for any travel associated with the
Activity/Trip, my signature below also acknowledges the following:
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I understand that the Institution assumes no liability or responsibility for the use of such vehicle during any such
travel and that the Institution has neither inquired about nor confirmed (a) the driving history, training or licensure
of the driver or (b) that the vehicle is covered by a private automobile insurance policy;
I understand that the Institution carries no insurance that could cover any damages, injuries, claims or other
liabilities associated with the use of such vehicle during such travel; and
I further understand that any private insurance policy covering such vehicle or the driver personally will be
responsible for any damages, injuries, claims or other liabilities that may arise from the use of the vehicle during
any travel associated with the Activity/Trip.
In consideration of Participant being permitted to participate in the Activity/Trip, I hereby accept all risk to
Participant’s health, including any injury or death to Participant that may result from such participation, which
participation includes all travel associated with the Activity/Trip, and I hereby release UTSA, its governing board,
officers, representatives, employees and agents from any and all liability to Participant, Participant’s personal
representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage
to Participant’s property and for any and all illness or injury to Participant’s person, including his or her death, that
may arise from or occur during Participant’s participation in the Activity/Trip, WHETHER CONTRIBUTED TO
OR CAUSED BY ANY NEGLIGENCE OF UTSA, ITS GOVERNING BOARD, OFFICERS, EMPLOYEES OR
REPRESENTATIVES, OR OTHERWISE.
I further agree to indemnify and hold harmless UTSA, its governing board, officers, representatives, employees and
agents from liability for the injury or death of any person(s) and damage to property that may arise, in whole or in
part, from Participant’s negligent or intentional act or omission while participating in the described Activity/Trip,
WHETHER CONTRIBUTED TO OR CAUSED BY ANY NEGLIGENCE OF UTSA, ITS GOVERNING BOARD,
OFFICERS, EMPLOYEES OR REPRESENTATIVES, OR OTHERWISE.
Signature of Participant or
Parent/Guardian
Printed Name of Signatory
Date
If Participant is at least 18 years of age OR Signature of Participant’s Parent/Guardian if Participant is under the age of 18
Signature of Witness
Printed Name of Witness
Date
Please choose which date of the camp you would like to participate in:
Monarch Butterfly Ecology: The summer camp is designed for kids 8-11 years old and will bring basic concepts in
monarch biology, ecology, and conservation. The camp will have hands-on butterfly education and generate interest in
wildlife conservation effort. Each day the camp covers a branch of ecology, i.e. developing a herbarium, a plant press, and
an insect collection.
___ July 11th-15th: Daily check in at 7 am and check out at 4 pm
___ July 18-22th: Daily check in at 7 am and check out at 4 pm
The cost of each camp is $230.
A $50 deposit is required to fully register.
Any money owed must be paid before the camp begins.
Please submit application to Julian Chavez at julian.chavez@utsa.edu or Fernando Martinez at
fernando.martinez@utsa.edu