Included in your child s enrollment packet you will find the following forms which must be submitted by June 9, 2013 along with a $10 camp fee:

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1 May 1, 2013 Dear Parents and Campers: Kansas City Indian Center will have their 32nd Annual American Indian Culture Camp beginning Wednesday, July 10 and ending Sunday, July 14 th. Counselors-In-Training will begin camping the evening of July 9 th for training and team building. CITs will be notified of the time at a later date. Camp will be held at the Rotary Club Youth Camp located at E Colbern Rd, Lee s Summit, Missouri. All Campers must be between the ages of Counselors in Training must be years of age. Campers may be dropped off no sooner than 10:30 am on July 10th and will need to be picked up at camp by 12:00 noon on July 14th. Included in your child s enrollment packet you will find the following forms which must be submitted by June 9, 2013 along with a $10 camp fee: *Camp Application *Emergency Contact and Medical Information *Release for Photo Image *Rotary Club Youth Camp Photo/Media Release Form * Camp Rules And Discipline Policy And Release Of Liability *Informed Consent and Waiver for Equine Activities *Informed Consent and Waiver for Inipi Ceremony *USDA Summer Food Service Program Income Eligibility Form THINGS TO BRING TO CAMP: Towels (two) Soap/shampoo Brush/comb Toothpaste/toothbrush Swimsuit Shirt/shorts Jacket/pants Sleeping bag/ Sandals/tennis shoes Insect repellant blankets, covers Pool shoes Raincoat/poncho Flashlight Sunscreen A Good Attitude THINGS NOT TO BRING TO CAMP: NO FOOD OF ANY KIND Weapons of any kind Jewelry Tobacco Products Magazines Radios/Tape Players Cameras Hand held video games Cell phones/pagers Pocketknives A Bad Attitude PARENTS: Camp is not responsible for loss or destruction of expensive and/or personal items. For safety reasons Campers MUST wear shoes/sandals (No Flip Flops) to the pool and at all times. If parents wish to donate food/snacks for camp, food must be left with the Camp Director in the administrative building. A contact phone number for Camp will be provided to parents when dropping their children off. Thank you, Teddy Tatum, Camp Director

2 Kansas City Indian Center W 39 th Street Kansas City, MO (816) American Indian Culture Camp Counselor Application 2013 Name: Age: Gender: Male Female Preferred Name Tribe(s) Street Address: City: State: Zip Code: Date of Birth: County: Children s Name(s) attending camp: Phone Number(s): H W C Address: Checklist o Volunteer Background Check Release and Volunteer Waiver Form o Things to bring to camp checklist o Read camp policies and procedures o Completed training o Completed USDA form o Completed KCIC volunteer form Person to Notify in case of emergency: Name: Phone: Street Address: City: State: Zip Code: T-Shirt Size Requested (check one): Child Sizes: Small Medium Large Adult Sizes: Small Medium Large XL XXL XXXL As a volunteer for KCIC, I have read and understand the policies of KCIC s American Indian Culture Camp and in signing this form, agree to said policies. Signature Date Form revised 5/13

3 Kansas City Indian Center W 39 th Street Kansas City, MO (816) Volunteer Background Check Release and Volunteer Waiver Form Volunteer Background Check Release In order to provide a safe and healthy environment for children, please understand we will review relevant public documents regarding criminal activity of any person who is in contact with children..if the background check indicates you have had any charges related to any crimes against children you will not be considered as a volunteer; in addition, the Kansas City Indian Center reserves the right to deny a volunteer position at any time for any reason. Name (Print): (Last) (First) (Middle Initial) Required Other Names Used: Address (street, city, state, zip): Home Phone: Cell Phone: E mail Address: Date of Birth: Sex: I authorize the Kansas City Indian Center to process my application for serving as a volunteer by reviewing my criminal background. I hereby release the Kansas City Indian Center, its employees, representatives and such individuals or organizations from all liability for any damage whatsoever incurred in obtaining or furnishing such information. By signing your name and dating this authorization, you are hereby confirming the accuracy of the information provided above and granting the Kansas City Indian Center permission to do a background check, as it deems necessary. Signature: Date: Volunteer Waiver It is my desire to perform volunteer services for the benefit of the Kansas City Indian Center. I understand that the Kansas City Indian Center is allowing me to perform these volunteer services subject to my complete understanding that the Kansas City Indian Center will not provide me with any type of insurance or other loss coverage. Based upon the above, I agree to indemnify, defend and hold harmless and release the Kansas City Indian Center and its elected and appointed officials, officers, employees and authorized representatives from and against any and all liability, loss, damage, expenses, costs (including attorney s fees) arising out of or in any way attributed to the activities performed at Kansas City Indian Center Culture Camp at Kansas City Rotary Camp 13 (site) on July 9 July 14, By Signing this agreement, I acknowledge that I have read it in its entirety, have given the terms due consideration, understand the terms and understand that I am freely and voluntarily giving up certain rights. I further intend that this agreement shall be binding upon all of my successors, heirs, assigns, receivers and the like. Today s Date: Signature of Volunteer or Parent/Guardian, if minor:

4 Emergency Contact and Medical Information for a Counselor Name Date of Birth Sex M F ([ ]) ([ ]) ([ ]) ([ ]) Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Alternative Emergency Contacts Primary Emergency Contact Secondary Emergency Contact ([ ]) ([ ]) ([ ]) ([ ]) Home Phone Work Phone Home Phone Work Phone Address Address City, ST ZIP Code City, ST ZIP Code Medical Information Hospital/Clinic Preference Physician s Name Phone Number Insurance Company Policy Number Allergies/Special Health Considerations I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the even that neither emergency contact person can be reached in the case of an emergency. Signature Date I give permission for my child to go on field trips. I release Kansas City Indian Center and individuals from liability in case of accident during activities related to Kansas City Indian Center Culture Camp, as long as normal safety procedures have been taken. Parent s/guardian s Signature Date Witness Signature Date

5 RELEASE FORM FOR PHOTO IMAGE, VOICE RECORDINGS, AND VIDEO IMAGE I hereby give the KANSAS CITY INDIAN CENTER and its sponsors and affiliates the absolute right and permission to copyright, publish, televise, and use photographs, or audio recordings, or video tapes of me, in which I may be included. Said images or recordings may be included within or utilized as illustrations, advertisements or publications, either in printed form, on television, or in digital format. I hereby certify and covenant that I am of legal age. (A parent or legal guardian must sign for a minor.) Print Name of Participant Print Name of Legal Guardian Signature of Legal Guardian and Relationship Date Street Address City, State Zip Code Phone Number Address 02/10/2011 GC

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7 American Indian Culture Camp 2013 Wednesday, July 10 th - Saturday, July 14 th Counselors-In-Training - Tuesday, July 9 th -Saturday, July 14 th CAMP RULES AND DISCIPLINE POLICY AND RELEASE OF LIABILITY 1. In order to keep children safe, any parent or guardian that wishes to visit a camper during camp must provide at least a 24-hour notice and must check in at the Administration Building and produce a driver s license. If you are listed not on the application as the parent or guardian, you will be asked to leave the premises. 2. Campers must treat other campers, camp staff and guests with Respect. This includes giving full attention to counselors, speakers and activity leaders. 3. Campers will not engage in physical violence, destructive behavior, name calling, verbal insults, hazing, bullying, theft, or possess/use drugs or alcohol. 4. No food of any kind is to be kept in cabins by the campers. 5. No weapons of any kind are allowed. Please do not bring jewelry, tobacco products, magazines, radios/mp3 players/cds, cameras, hand held video games, cell phones/pagers, or pocketknives. KCIC is not responsible for loss or destruction of expensive and/or personal items. 6. For safety reasons campers MUST wear shoes/sandals (No Flip Flops) to the pool and at all times. 7. All medication must be checked in with the Camp Director and kept in the Health Lodge. This includes over the counter medication. 8. Campers must remain in their cabin after lights out unless they have permission from their counselor. This list is not intended to be all inclusive. Campers are expected to follow any other rules and instructions set forth by the Rotary Camp and/or KCIC Camp Director. Violation of camp rules may result in being sent home.

8 I agree that my child will abide by the rules and discipline policy set forth by the Kansas City Indian Center Culture Camp Program while attending camp and participating in the activities. I assume full responsibility for any damage to person(s) or property caused by my child. I hereby give the Kansas City Indian Center Culture Camp Staff permission to seek medical attention for my child in the event that my contact persons or I cannot be reached and the medical treatment is absolutely necessary. I agree that the payment of such bills will be my sole responsibility. I agree to pick my child up from camp if the rules are not followed. I will be available to pick my child up when camp is over at 12:00 noon on Sunday, July 14 th, or make necessary arrangements to do so. If I do not pick up my child within one hour of pick up time and have not contacted the camp coordinators with arrangements for pick up, I understand that the proper authorities will be contacted. Signature of Parent or Guardian Date RELEASE OF LIABILITY CLAUSE I hereby expressly waive any claim of liability against the Kansas City Indian Center Culture Camp and Kansas City Rotary Club Youth Camp 13, including its employees and representatives, and release them from any and all liability in connection with the activities at Culture Camp Signature of Parent or Guardian Date ALL APPLICATIONS MUST BE COMPLETE IN ORDER TO ATTEND AND PARTICIPATE IN ACTIVITIES Kansas City Indian Center Culture Camp 600 West 39 th Street Kansas City, MO

9 Kansas City Indian Center 600 W 39 th Street Kansas City, MO www. kcindiancenter.org INFORMED CONSENT, WAIVER OF LIABILITY, RELEASE, & INDEMNIFICATION AGREEMENT FOR EQUINE ACTIVITIES WARNING Under Missouri law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to the Revised Statutes of Missouri. PLEASE READ CAREFULLY BEFORE SIGNING. DEATH OR SERIOUS INJURY MAY RESULT FROM YOUR PARTICIPATION IN THIS ACTIVITY. KANSAS CITY INDIAN CENTER AND KANSAS CITY ROTARY CAMP YOUTH CAMP 13 DOES NOT GUARANTEE YOUR SAFETY. A. I, the following individual listed as "Rider" and the parent or legal guardians thereof if a minor, do hereby voluntarily request and agree to participate in equine activies and that this rider will ride a horse provided at KANSAS CITY INDIAN CENTER CULTURE CAMP. RIDER: AGE (IF UNDER 18): LEGAL GUARDIAN/PARENT (IF MINOR): CONTACT IN CASE OF EMERGENCY (Name, address, phone number): LIMITATIONS: Does the rider have any physical or mental health problems which may affect his/her ability to participate in any equine activity? (Yes or No) If yes, please describe: B. AGREEMENT SCOPE, GOVERNING LAW AND DEFINITIONS: This agreement shall be legally binding upon me, the registered rider, and the parents and/or legal guardian's) thereof (if minor), my heirs, estate, assigns including all minor children and personal representatives. It shall be interpreted according to the laws of the State of Missouri. If any clause, phrase or word is in conflict with state law, then that single part is null and void. The term "Horse" herein shall refer to any equine animal as defined in Missouri Revised Statute, and particularly Section or otherwise handling of horses, whether from the ground or mounted and any other equine activity as defined therein. The term "Rider" shall herein refer to a person who rides a INFORMED CONSENT, WAIVER OF LIABILITY, RELEASE, & INDEMNIFICATION AGREEMENT FOR EQUINE ACTIVITIES Page 1

10 horse mounted or otherwise handles or come near a horse from the ground and any participant as defined in by said Statute. The term "I", "me", "my" shall herein refer to the above registered rider and the parents or legal guardians thereof if a minor. C. INHERENT RISKS: "Inherent risks of equine activities", those dangers or conditions which are an integral part of equine activities, including but not limited to: (a) The propensity of any equine to behave in ways that may result in injury, harm or death to persons on or around it; (b) The unpredictability of any equine's reaction to such things as sounds, sudden movement and unfamiliar objects, persons or other animals; (c) Certain hazards such as surface and subsurface conditions; (d) Collisions with other equines or objects; (e) The potential of a participant to act in a negligent manner that may contribute to injury to the participant or others, such as failing to maintain control over the animal or not acting within his ability; "Participant", any person, whether amateur or professional, who engages in an equine activity, whether or not a fee is paid to participate in the equine activity. D. ACCIDENTAL/MEDICAL INSURANCE: I AGREE THAT: Should medical treatment be required, I and/or my own accidental/medical insurance company shall pay for all such incurred expenses. E. LIABILITY RELEASE & INDEMNIFICATION: I AGREE THAT: In consideration of KANSAS CITY INDIAN CENTER allowing my participation in any equine activity, I, the rider and the parent or legal guardian thereof, if minor, hereby: 1. Release, waive, discharge, hold harmless and covenants not to demand, sue or otherwise claim from KANSAS CITY INDIAN CENTER AND KANSAS CITY ROTARY CAMP YOUTH CAMP 13,its premises, owners, affiliated organizations, equine activity sponsor, equine professional, lessor or operator of the equine facilities, equine owner or lessor, and each of them, their owners, agents, employees, officers, directors, shareholders, members (all herein collectively referred to as "Releasees") from all liability to the undersigned, his/her personal representatives, heirs, distributees, guardians, legal representatives, next of kin, and assigns, for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the Releasees or otherwise while the undersigned is in or upon restricted areas, and/or participating in any equine activity. 2. Agree to indemnify and to hold harmless the Releasees and each of them from any loss, liability, damage, or cost that they might incur due to the presence of the undersigned in or on the restricted area or in any way participating in any equine activity, whether caused by the negligence of the Releasees or otherwise. INFORMED CONSENT, WAIVER OF LIABILITY, RELEASE, & INDEMNIFICATION AGREEMENT FOR EQUINE ACTIVITIES Page 2

11 3. Assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while in or on a restricted area and/or while participating in any equine activity. I, the rider, and the parent or legal guardian thereof if a minor, expressly acknowledges and agrees that equine activities are very dangerous and involve the risk of serious injury and/or death and/or property damage. I, the rider, and the parent or legal guardian thereof, if a minor further expressly agrees that the above release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Missouri, and that if any portion of this agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. INHERENT RISKS OF EQUINE ACTIVITIES: I am aware of the clear risks associated with equine activities and am mindful of the provisions of Section as follows: WARNING - Under Missouri law, an equine professional not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to the Revised Statutes of Missouri. SIGNATORY S STATEMENT OF AWARENESS AND INFORMED CONSENT: I/WE THE RIDER, AND THE PARENT OR LEGAL GUARDIAN THEREOF IF MINOR, THE UNDERSIGNED, HAVE READ AND DO UNDERSTAND THE FOREGOING AGREEMENT, WARNINGS, RELEASE AND ASSUMPTION OF RISK AND HAS READ AND VOLUNTARILY SIGNS THIS AGREEMENT, AND FURTHER AGREES THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENTS APART FROM THE ABOVE WRITTEN AGREEMENT HAVE BEEN MADE BY ANY OF THE RELEASEES. THE UNDERSIGNED FURTHER ATTEST THAT ALL FACTS RELATED TO THE APPLICANT'S PHYSICAL CONDITION AND AGE ARE TRUE AND ACCURATE. IF ANY INFORMATION PROVIDED HEREIN CHANGES, THEN I/WE WILL IMMEDIATELY NOTIFY RELEASEES, OF SUCH CHANGE IN WRITING. I HEREBY GIVE THE KANSAS CITY INDIAN CENTER CULTURE CAMP STAFF PERMISSION TO SEEK MEDICAL ATTENTION FOR MY CHILD IN THE EVENT THAT MY CONTACT PERSONS OR I CANNOT BE REACHED AND THE MEDICAL TREATMENT IS ABSOLUTELY NECESSARY. I AGREE THAT THE PAYMENT OF SUCH BILLS WILL BE MY SOLE RESPONSIBILITY. I HEREBY GIVE PERMISSION FOR MY SON/DAUGHTER TO PARTICIPATE IN EQUINE ACTIVITIES. All riders and parents or Legal Guardians must sign below after reading this entire document. SIGNATURE OF RIDER SIGNATURE OF PARENT OR GUARDIAN DATE DATE INFORMED CONSENT, WAIVER OF LIABILITY, RELEASE, & INDEMNIFICATION AGREEMENT FOR EQUINE ACTIVITIES Page 3

12 Kansas City Indian Center 600 W 39 th Street Kansas City, MO (816) I HAVE READ AND UNDERSTAND THE FOLLOWING: INFORMED CONSENT FOR INIPI (SWEAT LODGE) CEREMONY 1. I understand that Inipi ceremonies (sweat lodge) involve exposure to heat, darkness and extremely hot rocks and a fire burning in the vicinity of the lodge and smoke. I understand that if I/my child, am/is suffering from any active medical conditions or taking any medications, it is my responsibility to discuss my/my child s participation in the Inipi ceremonies (sweat lodge) with my /my child s personal physician. Conditions that may be particularly affected by participation is such environments include but are not limited to pregnancy, heart conditions, kidney conditions, lung conditions, anxiety disorders such as claustrophobia, and any other medical conditions that may affect sweating, or body heat and fluid regulation. 2. I understand that any such concerns or conditions should be discussed with the Inipi ceremony (sweat lodge) leader prior to participation. 3. Participants are recommended to ensure that they have pre-hydrated themselves prior to the ceremony and that they maintain adequate intake of fluids after the ceremony. I, the following individual listed as "Participant" and the parent or legal guardians thereof if a minor, do hereby voluntarily request and agree to participate in Inipi ceremonies and that this Participant will participate in one or more Inipi ceremonies provided at KANSAS CITY INDIAN CENTER CULTURE CAMP. PARTICIPANT: AGE (IF UNDER 18): LEGAL GUARDIAN/PARENT (IF MINOR): CONTACT IN CASE OF EMERGENCY (Name, address, phone number): LIMITATIONS: Does the participant have any physical or mental health problems which may affect his/her ability to participate in any Inipi ceremony? (Yes or No) If yes, please describe: B. AGREEMENT SCOPE, GOVERNING LAW AND DEFINITIONS: This agreement shall be legally binding upon me, the registered participant, and the parents and/or legal guardians) thereof (if minor), my heirs, estate, assigns including all minor children and personal representatives. It shall be interpreted according to the laws of the State of Missouri. If any clause, phrase or word is in conflict with state law, then that single part is null and void. The term "I", "me", "my" shall herein refer to the above registered participant and the parents or legal guardians thereof if a minor. INFORMED CONSENT FOR INIPI (SWEAT LODGE) CEREMONY Page 1

13 C. LIABILITY RELEASE & INDEMNIFICATION: I AGREE THAT: In consideration of KANSAS CITY INDIAN CENTER allowing my participation in any Inipi ceremony (sweat lodge), I, the participant and the parent or legal guardian thereof, if minor, hereby: 1. Release, waive, discharge, hold harmless and covenants not to demand, sue or otherwise claim from KANSAS CITY INDIAN CENTER AND KANSAS CITY ROTARY CAMP YOUTH CAMP 13,its premises, owners, affiliated organizations, their owners, agents, employees, officers, directors, shareholders, members (all herein collectively referred to as "Releasees") from all liability to the undersigned, his/her personal representatives, heirs, distributees, guardians, legal representatives, next of kin, and assigns, for any and all loss or damage, and any claim or demands therefore on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of the Releasees or otherwise while the undersigned is participating in any Inipi ceremony. 2. Agree to indemnify and to hold harmless the Releasees and each of them from any loss, liability, damage, or cost that they might incur in any way participating in any Inipi ceremony (sweat lodge), whether caused by the negligence of the Releasees or otherwise. 3. Assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while participating in any Inipi ceremony (sweat lodge). I, the participant, and the parent or legal guardian thereof, if a minor further expressly agrees that the above release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Missouri, and that if any portion of this agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. SIGNATORY S STATEMENT OF AWARENESS AND INFORMED CONSENT: I/WE THE PARTICIPANT, AND THE PARENT OR LEGAL GUARDIAN THEREOF IF MINOR, THE UNDERSIGNED, HAVE READ AND DO UNDERSTAND THE FOREGOING AGREEMENT, RELEASE AND ASSUMPTION OF RISK AND HAS READ AND VOLUNTARILY SIGNS THIS AGREEMENT, AND FURTHER AGREES THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENTS APART FROM THE ABOVE WRITTEN AGREEMENT HAVE BEEN MADE BY ANY OF THE RELEASEES. THE UNDERSIGNED FURTHER ATTEST THAT ALL FACTS RELATED TO THE APPLICANT'S PHYSICAL CONDITION AND AGE ARE TRUE AND ACCURATE. IF ANY INFORMATION PROVIDED HEREIN CHANGES, THEN I/WE WILL IMMEDIATELY NOTIFY RELEASEES, OF SUCH CHANGE IN WRITING. I HEREBY GIVE THE KANSAS CITY INDIAN CENTER CULTURE CAMP STAFF PERMISSION TO SEEK MEDICAL ATTENTION FOR MY CHILD IN THE EVENT THAT MY CONTACT PERSONS OR I CANNOT BE REACHED AND THE MEDICAL TREATMENT IS ABSOLUTELY NECESSARY. I AGREE THAT THE PAYMENT OF SUCH BILLS WILL BE MY SOLE RESPONSIBILITY. I HEREBY GIVE PERMISSION FOR MY SON/DAUGHTER TO PARTICIPATE IN INIPI CEREMONY (SWEAT LODGE). All Participants and parents or Legal Guardians must sign below after reading this entire document in order to participate in Inipi ceremony (sweat lodge). SIGNATURE OF PARTICIPANT DATE SIGNATURE OF PARENT OR GUARDIAN DATE INFORMED CONSENT FOR INIPI (SWEAT LODGE) CEREMONY Page 2

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