SUMMER LEADERSHIP CAMP

Transcription

1 HARMONY SCIENCE ACADEMY 4401 San Francisco Ave, Laredo, TX Tel: Fax: Camp Area: Mo-Ranch Assembly Address: 2229 FM 1340, Hunt, TX Phone:(800) SUMMER LEADERSHIP CAMP Applications to Mr. Cetin College Readiness & Leadership Program Coordinator GENERAL OVERVIEW Location and s: The Program site is the comfortable, supportive and well-supervised camp and education facilities of the Mo-Ranch Assembly. BOYS: May 20th Friday 3:00 pm(from HSA-Laredo) until May 24th Tuesday 1 pm(to HSA-Laredo) GIRLS: May 24th Tuesday 3:00 pm(from HSA-Laredo) until May 28th 1pm(To HSA-Laredo) Camp Fee: $300 (payment plan:march, April, and May $100/month) The cost will include 4 nights lodging, 14 meals beginning with dinner,stem activities, team building, low and high ropes, orienteering, campfire, tubing, environmental classes, and use of the facilities 1

2 What to Bring to Mo-Ranch! Comfortable clothing & shoes (depending on the weather) Swimsuit & towel (seasonal) Flashlight (not essential - you don't need to buy one - bring one if you have it!) Toiletry items (towels, toothbrush, toothpaste, soap, shampoo, etc.) Bedding (sleeping bag or sheets & blanket) Pillow Camera / Video Camera (optional great memories!!)

3 SUMMER LEADERSHIP CAMP RELEASE AND WAIVER OF LIABILITY AGREEMENT This agreement is by and between Cosmos Foundation, Inc. d/b/a Harmony Public Schools ( Harmony ), a Texas Open-Enrollment Charter School, and the undersigned Student and Parent or Legal Guardian, and concerns the Student s participation in the HARMONY SUMMER LEADERSHIP CAMP. For the purposes of this agreement, the HARMONY SUMMER LEADERSHIP CAMP includes any activities involving use of the education facilities located at New Braunfels, including, but not limited to, educational instruction, group or individual study sessions, recreational activities, free play, food or beverage consumption, and sleeping. In addition, the HARMONY SUMMER LEADERSHIP CAMP may include activities conducted off the premises, as well as transportation to and from these activities. Information Student Name: Student ID #: Male: Female: School: Class/Grade Level: s of Participation: - Parent(s) or Legal Guardian(s): Address: Home Tel.: Work Tel.: Cell: Acknowledgement and Consent The undersigned Student and Parent/Legal Guardian hereby gives permission for the Student to participate in the Harmony Study Dorm Program and all related activities for the days indicated above. The undersigned has received and read all the information relating to the Harmony Study Dorm Program and is aware of the guidelines and policies applicable to the Student, including the rules of student conduct, during participation in the program. The undersigned acknowledges the risks and dangers associated with participation in the Harmony Study Dorm Program, which could result in property damage or bodily injury, including death or permanent injury, and may be caused by the action, inaction, or negligence on the part of Harmony, its Board of Directors, officers, servants, agents, or employees. Further, the undersigned acknowledges and accepts that there may be risks not known or not reasonably foreseeable at this time. THE UNDERSIGNED UNDERSTANDS AND ASSUMES ALL RISKS INHERENT TO THE HARMONY STUDY DORM PROGRAM AND RELATED ACTIVITIES, WHETHER KNOWN OR UNKNOWN, AND THAT BY SIGNING THIS DOCUMENT, IS GIVING UP ITS RIGHT TO SUE. Release and Waiver of Liability In consideration for permitting the Student to participate in the Harmony Study Dorm Program, the undersigned Student or Parent/Legal Guardian, on behalf of himself/herself, the minor Student, and his/her respective family members, spouses, heirs, assigns, and personal representatives, voluntarily RELEASES, WAIVES, DISCHARGES, and PROMISES NOT TO SUE Harmony Public Schools, its Board of Directors, or any of its officers, servants, agents, or employees (the Releasees ) from any and all liability, claims, demands, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, sustained by the Student, or to any property belonging to the Student, whether caused by the negligence of the Releasees, or otherwise, while participating in the Harmony Study Dorm Program, or while in, on or upon the premises where the Harmony Study Dorm Program is being conducted, or in transportation to and from said premises. All parties agree that this Release and Waiver of Liability shall be construed in accordance with the laws of the State of Texas, and that if any portion of this agreement is held invalid, the other provisions shall continue in full force and effect. This Release and Waiver of Liability shall be a bar to nay recovery by the Student and/or the Parent(s) or Legal Guardian(s) in any action instituted by any of them to recover for loss suffered as a result of participating in the Harmony Study Dorm Program. Signature of Student and Parent/Legal Guardian for Students Who Are Minors: I certify that I am the custodial parent or am the Legal Guardian of the Student. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND AGREE TO ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY AND AN ASSUMPTION OF RISK. Student s Signature: : Parent or Legal Guardian s Signature: : 2

4 SUMMER LEADERSHIP CAMP CONSENT TO MEDICAL TREATMENT/RELEASE Student Name: of Birth: Age: As the natural parent and/or the legally authorized guardian of the aforementioned minor, I grant my authorization and consent for the respective officers, directors, volunteers and employees of Cosmos Foundation, Inc. d/b/a Harmony Public Schools and the HARMONY SUMMER LEADERSHIP CAMP, to administer general first aid treatment for any minor injuries or illnesses experienced by the Student. If the injury or illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such treatment is to occur. It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical or emergency personnel. This authorization is effective commencing on the day of, 2015 and expiring on the day of, I agree to authorize release of any medical information to process insurance claims and request payment of benefits to the physicians or supplier for services described, and to provide any other consent(s) required by federal and state law to effectuate such release. I understand that should the insurance not cover this illness/injury, I will be responsible for payment in full of any charges incurred. MEDICAL HISTORY Does the Student have a known history of: (Circle Y/N) A. Birth Deformities (one eye, kidney, etc.) YES NO B. Medical conditions currently under treatment YES NO C. Preexisting injuries currently under treatment YES NO D. Fractures or other disability type injuries YES NO E. Allergy (drugs, food, asthma, etc.) YES NO F. Mental disorder or convulsions YES NO G. Known past illness of more than one week YES NO H. Contact lens or glasses YES NO Explain above questions answered yes I hereby state that Cosmos Foundation, Inc. d/b/a Harmony Public Schools and the Harmony Summer Ledaership Program are not responsible, individually or collectively, for any preexisting injury or illness of the above participant. Parent or Legal Guardian Signature (Required) Parent or Legal Guardian Name (Please Print) 3

5 PRESBYTERIAN MO-RANCH ASSEMBLY AGREEMENT TO PARTICIPATE, ASSUMPTION OF RISK INDEMNITY AGREEMENT AND RELEASE OF LIABILITY MINOR PARTICIPANT S NAME: Whereas, the above named participant (hereinafter referred to as participant ) wishes to be accepted for participation and take part in programs (hereinafter referred to as Programs ) to be organized, conducted, and supervised by Presbyterian Mo-Ranch Assembly of Hunt, Texas (hereinafter referred to as Mo-Ranch ); and in consideration of Mo-Ranch s action in allowing participant to participate in such Programs: The undersigned, as legal guardian of participant, acknowledges that during the said Programs that participant has requested to participate in, certain risks and dangers may occur. This include, but are not limited to the hazards of physically demanding activities, ropes courses and aquatic activities, accident or illness in remote places without medical facilities and the forces of nature. The undersigned further recognizes that these risks may include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents, which may occur. I further understand that in participating in the Programs that participant is requesting to participate in, participant will be exposed to the elements of nature, including temperature extremes and inclement weather. In consideration of, and for the right to participate in, Programs and services arranged for participant by Mo-Ranch, its Owners, Trustees, Directors, Officers, Employees, Agents, and/or Associates (herein after all called Mo-Ranch ), the undersigned hereby assumes all the above risks and any other ordinary risk incidental to the nature of Programs which are not specifically foreseeable. The undersigned also agrees to hold harmless and unconditionally indemnify Mo-Ranch, its Owners, Trustees, Directors, Officers, Employees, Agents, and/or Associates either to participant s person, property or both, or of any other person or party having a legal interest in participant s property or person, including but not limited to accidents, damages, or injuries caused by either, in whole, or in part by any negligent act or omission of Programs or Mo-Ranch or the Owners, Trustees, Directors, Officers, Employees, Agents, and/or Associates of either including but not limited to Mo-Ranch s sole negligence. The undersigned hereby gives permission and authorizes medical personnel selected by Mo-Ranch or its agents to provide any medical care for participant, which they believe to be required. This authorization is unlimited in scope including, but not limited to, authority to order injections, anesthesia, surgery, and other invasive medical procedures. The undersigned also understands and agrees to assume full financial responsibility for paying all costs and expenses associated with the provision of medical care for participant. Furthermore, the undersigned also agrees to assume full financial responsibility of any costs associated with any specialized means of evacuation necessary to transport participant to an appropriate medical care facility. The undersigned affirms that the health of participant is good and there is not ongoing physician s care or treatment for any undisclosed condition that bears upon participant s fitness to safely participate in the activities of Programs. In addition, certain health and medical information must be made known to the staff conducting the Program so that they are prepared to respond appropriately if the need arises. This information will be held in confidence. The undersigned also states that participant is not under, and will not be under, the influence of any chemical substances other than prescribed medication; including alcohol. The undersigned further states that any medication participant may be taking will not affect participant s full participation in Programs or affect participant s personal safety or the safety of others. The undersigned also understand that the participation of participant is entirely VOLUNTARY. Participant enters into this activity and takes full responsibility for their decision to participate, or not to participate, and agrees to follow all safety instruction and rules. Both parties irrevocably consent and submit to the jurisdiction and venue of the State and Federal Courts having jurisdiction of Kerr County, Texas in connection with any suit, action, or other proceeding concerning this Agreement and Release. If any dispute results, then both parties agree to binding arbitration. If any provision of this Agreement and Release is found to be unenforceable by a Court of the last resort, it is the parties intention that the Court should reform the unenforceable provision so as to best approximate the parties intent, and to enforce the provision as reformed. Agreement and Release for participation starting _ and ending Signature of Participant Signature of Parent/Legal Guardian Print Name Please check the following program(s) you will be participating in while at Mo-Ranch: Conference Environmental Leadership Program Summer Camps Day Camp Other PRESBYTERIAN MO-RANCH ASSEMBLY FM 1340, Hunt, TX , , (fax)

6 MO-RANCH SUMMER CAMPS OVER-THE-COUNTER MEDS, PHOTO AND TRANSPORTATION FORM CAMPER S NAME SESSION OVER-THE-COUNTER MEDICATIONS: I hereby give permission to the health care staff at Mo-Ranch to administer over-the-counter medications to the above named child as needed. Over-the-counter medications will be administered as prescribed in the Standing Orders from the Mo-Ranch Medical Doctor. Exceptions to the above: (please sign) PHOTO RELEASE: I understand that photographs, video and/or digital images (hereinafter images ), may be taken of my minor s participation in various activities while at Mo-Ranch. I understand that no names or personal contact information will accompany any images. I understand that these images may be used in web-site photo albums and other promotional materials and/or publications. I acknowledge below that I do consent to such images of my minor s likeness being taken and do not request compensation for the use of my minor s likeness. (please sign) TRANSPORTATION RELEASE: I give permission for the camper named above to be transported by Mo-Ranch staff in approved vehicles on and off premises for program activities, medical care, and shuttle to and from Mo-Ranch. I also grant permission for the people listed below to pick up my camper from Mo-Ranch. (please sign) Custodial parent or legal guardian (please print) Second custodial parent or legal guardian (please print) Additional pick up person (please print) State & Driver s License Number State & Driver s License Number State & Driver s License Number If your camper will be picked up earlier than the normal schedule, Camp staff must be notified in writing prior to the early departure. All people picking up a child, including the parent or legal guardian may be asked to show photo identification to Camp Staff. We will not release your camper to anyone other than the person(s) listed above. Custodial parent or legal guardian signature Mo-Ranch Summer Camps 2229 FM 1340 Hunt, Texas (830)