TEXAS RESIDENT CAMP PARTICIPANT FORMS (MINORS)

Transcription

1 TEXAS RESIDENT CAMP PARTICIPANT FORMS (MINORS) Your child has requested the opportunity to participate in a SeaWorld Camp (also referred to herein as Sea World camp or the Camp ). Please complete, sign, and return the attached forms to the appropriate park at least five weeks before your camp session. SeaWorld Texas ATTN: SeaWorld Resident Camp Sea World Drive San Antonio, Texas Camper Information, Insurance Information, Medication and Health History (pp. 2-4) Camper Examination by Licensed Medical Personnel (p. 5) Consent and Release for Medical Treatment (p.6) Photo Release (p. 7) Release of Liability, Voluntary Assumption of Risk, Indemnity Agreement (pp. 8-9) Camper Survey (All About Me)( p. 10) Code of Conduct Agreement (p. 11) Travel Information (p. 12) The information on these forms will help us provide appropriate care if or when necessary. Adult campers or legal parent/guardian of the camper may complete all information, with the exception of the Camper Examination by Licensed Medical Personnel. Any changes to information on these forms should be given to camp staff upon arrival to camp. Please provide us with complete information so the staff can be aware of all needs. CAMPERS CANNOT BEGIN PROGRAM ACTIVITIES UNTIL COMPLETED, SIGNED FORMS ARE ON FILE Page 1 of 12 Last edited February 8, 2017

2 CAMPER INFORMATION AND HEALTH HISTORY (COMPLETED BY GUARDIAN) Last Name First/Middle Name M/F Birth date Age at Camp Grade Entering in the Fall Camp date(s) If Camper is attending with a friend, Name of Friend Home address City State Zip Custodial Parent/Guardian Phone Mobile Phone (must be registered in US) Second Parent/Guardian or Emergency Contact Phone Mobile Phone (must be registered in US) Emergency Contact (If Above Not Available) Phone Relationship to Camper Is the participant covered by family medical/hospital insurance? Yes No If so, indicate carrier or plan name Group # Name of insured Relationship to participant Policyholder insurance ID number Name of family physician Phone Name of family dentist/orthodontist Phone Vaccines Status DTP, TD Up to date Yes No Tetanus Date Given: Up to date Yes No Polio Up to date Yes No Measles, Mumps, Rubella (MMR) Up to date Yes No Page 2 of 12 Last edited February 8, 2017

3 TELL US ABOUT YOUR CHILD Does the camper have any of the following? If so, please explain in the space provided. Allergies (including food, insect (bee) stings, asthma, penicillin or other drugs, etc.). How severe is the reaction? Disease (Hepatitis, Measles, heart disease/defect, epilepsy, diabetes etc.)? Dietary Restrictions Please list any special needs your camper requires (vegetarian, gluten-free, dairy-free, etc.)? Other Conditions (Migraines, nosebleeds, bed-wetting, sleepwalking, behavioral etc.) that we need to be aware of? The Camp day is longer, more physically active and more interactive than a typical school day. Does your camper require any physical or behavioral accommodations to have a successful camp experience? Does your camper exhibit/have any behaviors of concern the staff should be aware of? What events influences/ trigger these behaviors? How can the staff support your child if they display these behaviors at Camp? What, if any, accommodations are needed to support your child s learning style and socialization skills? If there are any specific things you would like to discuss with us before your child comes to Camp, please call us at Page 3 of 12 Last edited February 8, 2017

4 CAMPER MEDICATION INFORMATION AND OVER-THE-COUNTER RELEASE(COMPLETED BY GUARDIAN) Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely and/or ordered by a physician (including but not limited to rescue inhalers, epinephrine injectors or Benadryl. ALL PRESCRIPTION AND OVER THE COUNTER MEDICATION MUST BE IN THE ORIGINAL PACKAGING/BOTTLE that identifies the prescribing physician, the name of prescription medication, the dosage, and the frequency of administration. Please bring enough medication to last the duration of camp. Participant takes NO medications (including over-the-counter or nonprescription drugs) on a routine basis and has NO mediations prescribed or ordered by a physician. Participant takes the following medication (including over-the-counter or nonprescription drugs) on a routine basis or has the following medications prescribed or ordered by a physician Medication #1 Dosage Specific times taken Reason for taking Medication #2 Dosage Specific times taken Reason for taking Medication #3 Dosage Specific times taken Reason for taking Attach additional pages for more medications. Identify any other medications taken that the participant does/may not take during the summer: Our Health Services carry several Over-the-Counter (OTC) medications; therefore, OTC need not be sent with camper. Please contact us if you have questions regarding Over-the-Counter Medications. I, hereby give SeaWorld permission to administer the following over-the-counter medications, or suitable generic substitute, to the above participant, if the Medical staff deems it necessary. Dosages will be administered according to directions on the bottle unless a physician directs otherwise. I hereby certify that my child has not in the past shown any allergic or other adverse reaction to any of the medications which you are hereby authorized to administer. Please cross through any medications that you do not approve for use with your camper. Headache, General Pain Upset Stomach Diarrhea Menstrual cramps Poison Ivy Itching, Hives Coughs Sinus Headache/Congestion Sunburn Bee sting Cuts or scrapes Sore Lips Toothache/ sore gums Tylenol, Ibuprofen Pepto Bismol, Mylanta, Tums Imodium AD, Kaopectate Ibuprofen Calamine Lotion, Cortaid, Caldyphen, or Caladryl Benadryl Robitussin, Cepocol lozenges Dristan Cold, Pseudoephedrine with Tylenol, Sudafed Cool Gel or Burn Spray Stingkill Triple antibiotic ointment Blistex Orajel Parent/Guardian Signature Date Page 4 of 12 Last edited February 8, 2017

5 CAMPER EXAMINATION (COMPLETED BY LICENSED MEDICAL PERSONNEL) Camper Name Camp Date I have examined the proposed camp participant. Date of last examination BP Weight Height Physician Recommendations and Restrictions at Camp SeaWorld Adventure Camps are physically demanding programs. Camp activities include, but are not limited to, snorkeling, kayaking, carrying heavy equipment, and continuous walking, rope climbs, and play areas. Competitive swimming skills aren t necessary for the snorkeling programs, but it is recommended that participants feel comfortable swimming. Participants may have the opportunity to ride roller coasters and other theme park rides on which they may experience high speeds and gravity forces. Campers may also be in close proximity to many species of animals and in their habitats where they may encounter the animals and dander, feathers, or food items, including nuts or nut products. Please provide any necessary/additional information including current treatments, conditions, or recommendations for restricting any activities at camp. Please indicate if the participant is currently experiencing or has had any of the following conditions: Recent surgery Impairment or condition preventing normal seating or use of safety restraints Pregnancy History of joint dislocations High blood pressure Respiratory problems/ Asthma Heart condition Neck, back or bone problems Camper has had all immunizations/shots (DTP, TD, MMR, Polio, Tetanus) as prescribed by good medical practice (subject to the recommendation of Camper s own physician). Yes No (If checked, please list any not up to date) In my opinion, the above participant is is not able to participate in an active camp program. Licensed Medical Personnel s Name and Title Signature Date signed Address Phone Page 5 of 12 Last edited February 8, 2017

6 CONSENT AND RELEASE FOR MEDICAL TREATMENT (MINOR) I,, individually and/or the parent/guardian of, a minor, sign this Agreement on behalf of myself and/or my child/ward. In consideration of my and/or child s/ward s attendance and participation at the SeaWorld Adventure Camp and all associated activities and outings (collectively, the Camp ), I execute this Consent for Medical Treatment (the Consent ) with SEA WORLD OF TEXAS LLC, its parents, subsidiaries, related and affiliated entities, and their officers, members, directors, partners, shareholders, employees, agents, insurers, successors and assigns (collectively, SEA ). I understand and agree that this Consent shall be binding on me and my child/ward, as well as the representatives, executors, heirs, next of kin, administrators, beneficiaries, successors and assigns of my child/ward. I represent and agree that I have the legal capacity and authority to act for and on behalf of myself and/or my child/ward. Beginning on the first day of my or my child/ward s presence at, attendance and/or participation in the Camp and continuing from day to day throughout the time I and/or my child/ward is present at, attends, and/or participates in the Camp, I hereby authorize any licensed physician, emergency medical technician, paramedics, nurses, hospital or other medical or health care facility or provider ( Medical Provider ) to provide medical care to me and/or my child/ward for any illness, injury, and/or condition that occurs, manifests or arises at the Camp. I further authorize any such Medical Provider to perform all procedures or services deemed medically advisable to treat or relieve, or to attempt to treat or relieve, any illness, injury, and/or condition. I acknowledge that there is a risk of complications and unforeseen consequences in any medical treatment. IN CONSIDERATION FOR ME AND/OR CHILD/WARD BEING ALLOWED TO PARTICIPATE IN THE CAMP, I, FOR MYSELF, AND/OR ON BEHALF OF MY CHILD/WARD AND ALL OTHERS ASSERTING RIGHTS BY, THROUGH, UNDER OR ON BEHALF OF ME AND/OR MY CHILD/WARD, DO HEREBY RELEASE, ACQUIT AND HOLD HARMLESS SEA FROM ANY AND ALL CLAIMS AND/OR DAMAGES ARISING FROM OR IN ANY WAY RELATED TO ANY MEDICAL TREATMENT, MEDICATION AND/OR HEALTH CARE ADMINISTERED TO MY CHILD/WARD, INCLUDING THE TIMING AND MANNER IN WHICH ANY SUCH TREATMENT, MEDICATION OR CARE IS ADMINISTERED TO MY CHILD/WARD, REGARDLESS OF WHETHER SUCH CLAIMS AND/OR DAMAGES WERE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OR ANY OTHER ACT, OMISSION, FAULT OR CONDUCT OF SEA. I acknowledge that no warranty is being made as to the result of any medical treatment. I agree that any health history provided by me or my child/ward is correct to the best of my knowledge. Concerning my child/ward, I acknowledge having knowledge and experience with the health and capabilities of my child/ward superior to Camp staff. I certify that I and/or my child/ward am/is in good health and does not have any health or mental / physical impairments or conditions that would be aggravated by attendance or participation at the Camp or that make such attendance or participation unsafe or otherwise inappropriate for me and/or my child. A copy of this Consent may be used in place of the original. I acknowledge and agree that this Agreement is intended to be as broad and inclusive as permitted by law. If any provision is invalidated or unenforceable, the remaining terms of the Agreement shall not be affected thereby but shall be valid and enforceable to the fullest extent permitted by law. The invalid provision shall automatically be replaced by a substitute provision which is valid and as nearly as possible maintains the same purposes and intention of the invalidated or unenforceable provision. I acknowledge and agree that this Agreement shall be interpreted in accordance with the laws of the State of Texas. I HAVE READ AND UNDERSTAND THE FOREGOING AND ACCEPT AND AGREE TO ITS TERMS. Signature of Parent/Guardian: Date: Printed Name of Parent/Guardian: Printed Name of Child/Ward: Relationship to Child/Ward: Name(s) of Parents, Guardian(s) and/or Managing Conservator(s) (if different from person signing this form): Page 6 of 12 Last edited February 8, 2017

7 PHOTO RELEASE I,, the parent/legal guardian of, a minor participant, in consideration of being permitted to participate in the SeaWorld Adventure Camps (the Camp ), do hereby on my own behalf and/or on behalf of the minor participant grant SEA WORLD OF TEXAS LLC, its parent, subsidiaries, all related and affiliated entities, and their officers, directors, members, partners, shareholders, employees, agents, successors and assigns (collectively referred to as SEA ), the irrevocable right and permission to photograph or otherwise record me or my child/ward in connection with the Camp, and to use any such photograph or recording ( Photograph ) for all purposes, including advertising and promotional purposes, in any manner in any and all media now or hereafter known, in perpetuity throughout the world, without restriction as to alteration. I waive any right to inspect or approve the use of the Photograph, and acknowledge and agree that the rights granted by this Release are without compensation of any kind. I acknowledge and agree that I have no right, title or interest in the Photographs and agree that such Photographs and the copyright therein are the exclusive property of SEA. I hereby release and discharge SEA from any and all claims and demands arising out of or in connection with the use of the Photographs, including but not limited to any and all claims for invasion of privacy or right of publicity. I represent and agree that I have the legal capacity and authority to act for and on behalf of myself and/ or for and on behalf of the minor participant. This release shall be binding upon me and/or the minor participant, and my or the minor participant s heirs, executors, representatives, next of kin, beneficiaries, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE FOREGOING RELEASE AND ACCEPT AND AGREE TO ITS TERMS AND SIGN IT VOLUNTARILY. Signature of Parent/Guardian: Date: Printed Name of Parent/Guardian: Printed Name of Child/Ward: Decline use of Photograph Date Page 7 of 12 Last edited February 8, 2017

8 RELEASE OF LIABILITY AND INDEMNITY AGREEMENT (COMPLETED BY GUARDIAN AND CAMPER) Thank you for participating in the SeaWorld Adventure Camps (hereinafter Camp ). In consideration of and as a condition for your participation or the participation of your child/ward in the Camp, you hereby accept the following terms and voluntarily and enter into this Release of Liability and Indemnity Agreement ( Agreement ). Please carefully read and consider the terms of this Agreement. Sign in the space at the end to indicate your understanding and acceptance of such terms and your entry into the Agreement on behalf of yourself and/or your child/ward. 1. I,, individually or as parent/natural guardian of a minor, sign this Agreement on behalf of myself and my child/ward and all others asserting rights by, through, under or on behalf of me and/or my child/ward. I acknowledge receipt of written materials and instructions relating to the Camp and assert that I have had an opportunity, prior to enrolling myself and/or my child/ward in the Camp, to review these materials which include but are not limited to: Resident Camp Parent Handbook. As a condition of the attendance and participation by me and/or my child/ward at the Camp, I agree that I and/or my child/ward will abide by the policies of the Camp and instructions of Camp staff. I understand that the Camp has the right to refuse or remove any participant who fails to obey such policies or instructions. 2. If signing on behalf of a child or ward, I acknowledge that I am the natural parent (biological or adoptive) of the child/ward and that I also have legal custody of the child/ward and that I have the authority to enter into this Agreement on behalf of my child/ward. 3. I acknowledge having knowledge and experience with the health and capabilities of my child/ward superior to Camp staff. I certify that I and/or my child/ward is/are in good health and does/do not have any health or mental / physical impairments or conditions that would be aggravated by attendance or participation at the Camp or that make such attendance or participation unsafe or otherwise inappropriate for myself or my child/ward, the animals at the Camp, or other participants. I further certify that I and/or my child/ward does/do not currently have upper respiratory disease, including asthma or illness (e.g., colds, flu, etc.), I and/or my child/ward is/am not on medication that suppresses immune function or has possible side effects that would interfere with the Camp, and that I and/or my child/ward does/do not have open sores, open wounds, cuts, abrasions, skin irritations or other outward signs of illness. 4. I understand that attendance and participation at the Camp may include riding roller coasters and other theme park rides and activities which may involve high speeds and exposure to certain gravity forces, swimming, snorkeling, kayaking, zip lines, rope climbs, play areas, ball games, carrying heavy equipment, continuous walking, vehicle transportation to and from activities, being in proximity of or interacting with, feeding and coming in physical contact with birds, reptiles, and primates, large felines, manatees, whales, dolphins, and other land or marine animals. I understand that there are inherent RISKS involved in these activities, including but not limited to scrapes, bites, cuts, bruises and/or more serious injuries or illnesses such as bodily injury, even death. I and/or my child/ward have voluntarily enrolled in the Camp and agree to ASSUME ALL RISKS, known and unknown, of personal injuries, possible death and damage to or loss of property stemming from attendance and participation at the Camp, transportation to and from the Camp or Camp activities, and presence at the camp site, the site of any Camp activities, or at any location while attending the Camp. 5. I agree to RELEASE SEA WORLD OF TEXAS LLC, its parents, all subsidiaries, related and affiliated companies, and their officers, members, directors, shareholders, employees, agents, successor and assigns including but not limited to Sea World Parks & Entertainment, Inc. (the Released Parties ) from any and all claims, losses, demands, damages, expenses, lawsuits, causes of action and judgments, whether foreseen or unforeseen, known or unknown, present or future, resulting from, arising out of or in any way connected with my and/or child/ward s participation in the Camp including but not limited to, any Page 8 of 12 Last edited February 8, 2017

9 claims for personal injuries, including death, illnesses and/or damage to or loss of personal property, EVEN IF CAUSED IN WHOLE OR IN PART BY THE PRESENT OR FUTURE NEGLIGENCE, FAULT, STRICT PRODUCT LIABILITY, BREACH OF CONTRACT OR OTHER ACT, CONDUCT OR STATUS OF ANY OF THE RELEASED PARTIES. 6. I further agree to INDEMNIFY AND DEFEND THE RELEASED PARTIES from and against any claims, actions, damages, demands, costs, expenses (including attorneys fees) or lawsuits, whether foreseen or unforeseen, present or future, known or unknown, that I, my child/ward, or any other parent/guardian of my child/ward may have or assert as arising from attendance or participation (or the refusal of permission to attend or participate) at the Camp, EVEN IF CAUSED IN WHOLE OR IN PART BY THE PRESENT OR FUTURE NEGLIGENCE, FAULT, STRICT PRODUCT LIABILITY, BREACH OF CONTRACT OR OTHER ACT, CONDUCT OR STATUS OF ANY OF THE RELEASED PARTIES. I understand and agree that this indemnity obligation includes any claims, actions, damages or lawsuits brought by or on behalf of my child/ward, including those for personal injuries, illness or damage to or loss of property arising from attendance or participation (or refusal of permission to attend or participate) at the Camp. 7. I acknowledge and agree that this Agreement is intended to be as broad and inclusive as permitted by law. If any provision is invalidated or unenforceable, the remaining terms of the Agreement shall not be affected thereby but shall be valid and enforceable to the fullest extent permitted by law. The invalid provision shall automatically be replaced by a substitute provision which is valid and as nearly as possible maintains the same purposes and intention of the invalidated or unenforceable provision. 8. I acknowledge and agree that this Agreement shall be interpreted in accordance with the laws of the State of Texas and that any dispute arising from the enforceability and/or interpretation of this Release shall be filed in a court of competent jurisdiction in Texas. 9. I agree that this Release shall be binding upon my and/or child/ward s family members, heirs and all others asserting rights, by through, under or on behalf of me and/or my child/ward. I AM OF AT LEAST 18 YEARS OF AGE, AM OF SOUND MIND, HAVE READ AND UNDERSTAND THE FOREGOING AND ACCEPT AND VOLUNTARILY AGREE TO ITS TERMS. Signature of Parent/Guardian: Date: Printed Name of Parent/Guardian: Printed Name of Child/Ward: Address of Guardian: Page 9 of 12 Last edited February 8, 2017

10 All About Me! Please have your child fill out this sheet and return it with the rest of the health and release forms. Is there a specific career with animals you re interested in? What was your favorite experience from Career Camp? What are you looking forward to the most at Advanced Career Camp? What advice do you have for a first time Career Camp camper? Did Career Camp inspire any changes in your day to day life or in planning for the future? If you were a camp counselor, what would you want each camper to learn from Camp? If there s anything else you d like to share with us, feel free to include it on a separate page. Page 10 of 12 Last edited February 8, 2017

11 CODE OF CONDUCT AGREEMENT (COMPLETED BY CAMPER AND GUARDIAN) This statement, when signed by both camper and parent, serves as an agreement with SeaWorld. Due to the nature of the SeaWorld Adventure Camp programs, all participants are expected to act in a responsible and courteous manner at all times. Upon arrival to the program, SeaWorld Instructors will review examples of acceptable and unacceptable behavior. Participants are expected to adhere to the guidelines set forth by the SeaWorld Instructors. If a behavior problem arises, the Instructors will first discuss the problem with the individual. If the problem continues, the participant may forfeit participation in future program activities. If the problems are severe, the parent/guardian will be contacted to discuss the problem. Finally, if the problem is not rectified, the parent/guardian is responsible for providing transportation for the participant to leave the program and a refund will not be issued. Examples of behavior that may result in a participant leaving a program include, but are not limited to, consumption or possession of alcohol; use or possession of tobacco products or illegal narcotics; possession of a weapon; destruction of property; stealing; and entering the sleeping area of the opposite gender. Participant: I have read and understand the above statement. By signing this agreement, I agree to act in a responsible and courteous manner at all times. If I do not follow the guidelines set forth by the SeaWorld Instructors, I understand that I may forfeit my participation in program activities. Participant name (print) Participant Signature Parent/Guardian: I have read and understand the above statement. By signing this statement, I agree to arrange and pay for transportation if my child must leave the program early. Parent/Guardian name (print) Parent/Guardian Signature Page 11 of 12 Last edited February 8, 2017

12 SeaWorld San Antonio Travel Information Participant Name: Name on your nametag: Please check only ONE form of travel for drop off and pick up to SeaWorld San Antonio. Yes, my child will be traveling by car and will be dropped off/picked up Camper Drop Off Drop Off Person: Driver s License # (Required): Relationship: Camper Pick Up Pick Up Person: Driver s License # (Required): Relationship: Yes, I will be traveling by air and needs pick up and drop off at the airport Camper will need to meet the camp staff at baggage claim. Reminder: For the flight home campers will be escorted to the security check point and then from there the camper will need to go to the gate. My camper s flight ticket has been upgraded, with the airlines, to unaccompanied minor and will need to be met at the gate. Reminder: If you wish your child to fly as an unaccompanied minor for the flight backhome, please make arrangements with the airline prior to the flight, or make sure your child has money designated to pay the extra upgrade fee. If your travel arrangements fall outside of time windows below travel fees must be paid by calling : Flight arrivals MUST be no earlier than 10:00 AM and no later than 2:00 PM on first day of camp. Flight departures MUST be after 8:00 AM and before 1:00 PM on the last day of camp. - $25 fee for outside of the times above for both arrival and departure times - $100 fee for staying before/after the first/last day of camp (This includes campers that are staying over from one session to the next) Airline Travel Information Arrival Information: Date: Airline: Time: Flight #: Departure Information: Date: Airline: Time: Flight #: Please refer to your Handbook on pages 2-3 for more information on travel and unaccompanied minors. Page 12 of 12 Last edited February 8, 2017