Activity Participation Agreement

Transcription

1 Activity Participation Agreement Activity Information (To be completed by the activity sponsor) Name of sponsoring organization: Address: Name of sponsor s coordinator: Description of activity: Date(s) and location of activity: Telephone: Telephone: Participant Information (To be completed by participant or authorized guardian) Name of participant: Name of parents/guardians: Address: Telephone: Name of emergency contact: Telephone (Day): Telephone (evening): List allergies or medical conditions: Is sponsor authorized to approve medical treatment? Yes No Is participant covered by personal/family medical insurance? Yes No If yes, name of insurer: Policy or group number: Participation Agreement I acknowledge that participation in the activity described above involves risk to the Participant (and to Participant s parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the activity described above (the Activity ), the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the Activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the Activity or during transportation to and from the activity, as well as for any medical treatment rendered to the Participant that is authorized by the Sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the Activity Sponsor ). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association. Signature: Signature: Date: Date:

2 General Guidelines Camp Dress Since this is a Christian youth camp, we ask all campers/leaders to dress with this in mind. The following is CBU s Policy: Undergarments are not displayed. Shorts, skirts, and dresses are at a length that will allow the wearer s finger tips to touch the garment when arms and hands are fully extended, while standing. All forms of clothing cover the wearer s midriff and, for females, the chest/bust area as well. The length of garments worn on the upper torso (i.e. shirts, tanks, blouses, sweaters) must cover or be covered by the wearer s waist band while standing. No tube tops or spaghetti straps are allowed. Tank tops may be worn but straps must be two inches wide or wider All forms of clothing cover or rest on or above a wearer s hips. Swim suits Females: swimwear must be a one-piece suit (no tankinis), covering cleavage, bust, and midriff areas; Thong, g-string and high French-cut styles are not acceptable. T-shirts are not to be worn over swimwear. Males: swimwear must be boxer style suits with at least a 5 inch inseam & nylon or mesh liner. Bare feet are prohibited in all areas except Aquatic Center. Lewd clothing and clothing which displays alcohol, tobacco products, satanic symbols, and inappropriate language and/or symbols, is not permitted. Other Policy Skate boards are only to be used for transportation from one place to another. No tricks of any kind will be permitted. (Boards will be taken away from students doing tricks and not returned until the last night of camp and only returned to the Youth Pastor.) Camp Discipline Concerning any discipline problem: The first level of resolution will be between the camper and his/her leader. If the problem is not resolved between camper and leader, the Camp Director will meet with all parties involved. If the problem cannot be resolved, it could result in the camper being sent home early by bus at the church s expense. Don t Forget to Pack Health Form, Medical Release form, and Rockwall form if desired; filled out and signed for each camper Bible, notebook, pencil Sleeping bag or bed roll and pillow Towels, washcloth, etc. Toiletries: soap, shampoo, toothbrush, etc. Clothes for 6 days keeping in mind there will be time for worship, games, sports, etc. Close-toed shoes and work clothes for Mission Track Flashlight (There are not many street lights on campus!) A water bottle to use for the week. We need to hydrate! Postcards, stationery, stamps to write home, if desired Swim suits see above for guidelines Towel for pool Extra spending money for Snack Bar COOPERATIVE SPIRIT AND ENTHUSIASM

3 What will get you sent home to Mom just leave this stuff at home Undesirable literature Knives, firearms, ammunition or other weapons (air soft guns or any simulation of a firearm) Food fights Fireworks, explosives and/or highly flammable materials Pets Profanity, abusive or inconsiderate language Excessive noise Controlled substances, alcohol, or tobacco Gambling Water balloons or shaving cream (except for the purpose of shaving) Use of candles, matches, or any type of open flame within buildings. Romance, leave all that at home Roller-skating / roller-blading

4 Health Form Instructions (2 pages, Due at Camp) Health forms are required for everyone attending Zona Camp. This is required by the Arizona Southern Baptist Convention and California Baptist University. You will turn in the originals to the nurse at registration. You should keep a set of copies with you in case you need them during times you are not on campus. Even students whose parents are present need to turn in forms since they will not always be together during this week. ZONA CAMP/CALIFORNIA BAPTIST UNIVERSITY HEALTH FORM Zona Experience Mission Life Worship Catalyst Impact Name of your church City Name M F Birth Date Age Name Parent or Guardian Home or Work Phone Home Address (Please include City, State, Zip) Mother s Cell Phone Father s Cell Phone In Case of Emergency, Notify: Phone Home Address (Please include City, State, Zip) ***************************************************************************** HEALTH CONDITION: Excellent Good Poor Please list any health or medical information about camper that we should know: Date of last immunization: DPT or TD Tetanus Polio Measles Rubella Mumps Please list camper's allergies (food, medication, insects, other): IMPORTANT: Do you carry medical/hospital insurance? If so, indicate: Carrier Policy or Group number Name of family physician Telephone PLEASE NOTE: The camp insurance is accident only and only to be considered secondary insurance. Health Form page 1 of 2

5 OVER-THE-COUNTER MEDICATION PERMIT Following is a list of over-the-counter medications. Please mark a line through any item you would not want used for your child. Acetaminophen (Tylenol) Cepastat (throat lozenge) Pepto-Bismol Tums Kaopectate Mylanta (liquid) Milk of Magnesia Sudafed (decongestant) Chlor-trimeton (antihistamine) Actifed (antihistamine and decongestant) Robitussin Gatorade Benadryl Camphophenique Betadine for wound care Hydrogen Peroxide for wound care Neosporin for wound care Polysporin for wound care Hydrocortisone Ointment for allergic skin rash AUTHORIZATION TO MEDICATE MINOR CAMPER OR STAFF MEMBER Must be filled out if camper is bringing medication to camp I hereby request that the below-listed medication(s) be given to my child. This will be handled by one of the leaders from our church group, unless otherwise requested. Please give complete information for each medication camper brings to camp. All medication must be in original container with prescription instructions in your child's name. NAME OF MEDICATION DOSAGE FREQUENCY WHAT IT IS FOR Signed (Parent or Guardian and Date) Health Form page 2 of 2

6 Medical Authorization and Release Agreement (3 Pages Due at Camp) Please use one form for each attendee* Zona Camp reserves the right to use photos and videos taken during events/projects for promotional and recognition purposes. This could include publishing in newsletter, collateral materials and website and broadcast. IMPORTANT! MUST BE COMPLETED FOR ATTENDANCE PARENT'S AUTHORIZATION: I give (child) permission to participate in all Zona Camp activities, July 10 th to 15th, 2016, under the direct supervision of sponsors of Church. I understand that in the event medical treatment is required, every effort will be made to contact me. However, if I can t be reached, I give my permission that in the case of accident or medical emergency, my child may be treated by a qualified physician selected by Conference Center personnel. I further agree to assume the obligation to pay doctor bills, telephone calls or any other expense relating to the emergency other than that paid by camp insurance. The camp insurance will pay as secondary insurance for medical care needed by campers who suffer bodily injury in accidents which occur at camp. No condition of illness other than accidental injury is covered by camp insurance. Signed Date (Parent or guardian) As consideration for California Baptist University s permission to use its facilities and services: I knowingly and voluntarily release, acquit and forever discharge California Baptist University and their related persons from any and all charges, complaints, claims, liabilities, obligations, promises, agreements, controversies, damages, actions, causes of action, suits, rights, demands, costs, losses, debts, and expenses of any nature whatsoever, known or unknown, suspected or unsuspected, foreseen or unforeseen, matured or unmatured, which exist, have existed, or may arise from any matter whatsoever occurring, including, but not limited to, any claims arising out of or in any way related to my and my dependents presence on the campus of California Baptist University which I or my dependents have or hereafter may have, own or hold against California Baptist University or their related persons. In case of illness or injury, I hereby authorize emergency medical treatment for myself or my unaccompanied minor children (named below) and agree to assume full responsibility for any such treatment, including payment of costs and any claims arising from or associated with such medical treatment. By executing this Release Agreement, I am waiving all my and my dependents claims against California Baptist University and their related persons arising under common law or any federal, state or local laws of any state. I understand that if my child is involved in Mission Life Experience they will be going off campus for up to 7 hours Monday - Thursday of camp. Zona Camp will provide transportation to and from the mission site. Print Name Sign Name Date Name of Unaccompanied Minor Child: * Even if you are attending camp along with your child/children, there may be times when you and your child/children are attending separate activities; therefore it is important that we have a separate Medical Authorization for each of you in the event of a medical emergency. Page 1 of 3

7 (Continued) RECREATION arc ENROLLMENT FORM THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS. YOU MUST READ IT CAREFULLY AND THOROUGHLY UNDERSTAND ITS RAMIFICATIONS BEFORE SIGNING WHICH WILL BE EVIDENCED AND ACKNOWLEDGED BY YOUR SIGNATURE AND INITIALS SET FORTH BELOW. DO NOT SIGN IT OTHERWISE. RELEASE OF LIABILITY AND ASSUMPTION OF RISK Please PRINT CLEARLY and fill in all blanks: Participant s Name: Grade: Male: Female: Participant s Date of Birth: / / Participant s Home Address: Street City Zip Participant s Home Phone Number: address: Health Insurance Co.: Policy/Group: Emergency Contact (even if present today): Name: Relationship: Cell Phone Number: Special Needs, Circumstances, or Dietary Restrictions: DUTY OF PARTICIPANTS: Some recreational activities conducted by Good Sports Plus Ltd., a California corporation doing business as arc ( arc ) may be hazardous to and create risks for participants. All participants have an obligation and duty to act as a reasonably prudent person when participating and engaging in the recreational activities offered by arc. If a participant cannot abide by the foregoing, the participant should not join in the activities and should advise the on-site representative of arc at once. The onsite representative of arc will determine in the sole judgment how to proceed. I/We, the undersigned, hereby promise, covenant and agree: a) to immediately, fully and diligently follow the directions and instructions of the on-site representative of arc. b) not to act in any way which shall interfere with the running or operation of rock climbing, kayaking, mountain biking, or any other activity (the Activities ) when such activities are conducted by arc. c) not to act in any which shall interfere with arc or the on-site representative of arc and their administration, the supervision or the conduct of the Activities or arc business. d) not to use any of arc equipment or facilities or services if I do not have the ability to use such facilities, equipment, or services safely without instructions and until I have requested and received sufficient instruction to permit safe usage as determined by arc. e) not to use any of arc equipment or facilities or services without the permission of the on-site representative of arc or after any prior permission has been revoked. f) not to engage in any dangerous, unsupervised or harmful conduct or willfully or negligently engage in any type of conduct which threatens or contributes to or causes any injury to any person including myself during, before or after the Activities have commenced. g) not to embark in any self-initiated activity without first informing the on-site representative of arc of my intentions and receiving permission from arc to engage in such self-initiated activity. h) not to violate the foregoing and/or any other rules of arc and shall allow the on-site representative of arc, at their sole discretion, to terminate my participation in the Activities. understand that arc reserves the right to cancel or change programs or activities as listed in their brochures when necessary. i) understand that arc is not responsible for the loss or damage to my child s personal belongings. j) agree to accept full responsibility, financial or otherwise, for the conduct of my child. In order to make each participant s experience fun, safe and rewarding, we hold high expectations in attitude and behavior. arc or the school/organization may dismiss a child at any time (prior to or during a trip) for disciplinary reasons. I have read and agree to the terms (Initials): Page 2 of 3

8 ACKNOWLEDGMENT AND ACCEPTANCE OF RISK: The undersigned fully understands and acknowledges that the activity which the Participant is about to voluntarily engage in as a participant and/or volunteer bears certain known/unknown physical risks and unanticipated risks or chances for accidents which could result in injury, disability, death, illness of disease, physical or mental, or damage to the Participant, to the Participant s property, or to spectators or other third-parties. The undersigned fully and completely accepts and assumes all responsibility and risk for injury, disability, death, illness, or disease, or damage to the Participant and the Participant s property. Participation in the Activities is purely voluntary; no one is requiring or forcing the Participant to participate, and the undersigned elects to freely and knowingly participate in spite of all known and unknown risks and possibilities of adverse consequences. The undersigned further acknowledges that without the foregoing statement, arc would not have agreed to allow the Participant to participate in the Activities. PICTURES AND PUBLICITY: All likenesses, pictures, videos, and recordings of any type or nature no matter the format, taken or produced in connection with the arc programs are the sole and exclusive property of arc and may be used in any promotional materials or in any publicity endeavors The undersigned grants permission for the foregoing use without need for any further consent, payment or signed release. RELEASE: In consideration of the services and/or property provided, the undersigned for myself and any minor children for which I am the parent, legal guardian, or otherwise responsible, any heirs, personal representatives, or assigns, do hereby fully release and hold harmless arc, its principals, directors, shareholders, officers, agents, employees, and volunteers from any and all liability, expense (including attorney s fees), loss or charge associated with the Activities, and further waive any cause of action (whether in tort, contract or strict liability) or complaint for any damage whatsoever arising from or related to any cause whatsoever (except that which is gross negligence or intentional misconduct solely by arc). I further agree to indemnify, defend and/or reimburse arc for any and all attorney s fees and costs arc or its principals, directors, shareholders, officers, agents, employees, and volunteers may incur should I bring legal action against arc and lose. arc shall not have had to incur any costs to claim the benefits of this indemnity. The release, waiver, indemnity, right of defense and reimbursement shall survive the termination of the Activity and have no limit in scope or duration. The undersigned specifically and knowingly releases all rights under California Civil Code Section 1542 which provides: A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR. ENTIRE AGREEMENT: I understand that this is the entire agreement between myself and arc, its agents or employees, and that it cannot be modified or changed in any way by the representatives or statements of any employees of arc or by me unless in writing signed by the President of arc. My (Our) signature(s) below indicates that I/We have read this entire document and understand it completely and agree to be bound by its terms. PARENT/GUARDIAN (if Participant is under 18) DATE: SIGNATURE OF PARTICIPANT DATE: I have read and agree to the terms (Initials): Page 3 of 3