UH Cougar Cub Summer Camp 2017 Registration Form (Please complete one form per camper)

Transcription

1 UH Cougar Cub Summer Camp 2017 Registration Form (Please complete one form per camper) CAMPER INFORMATION Child s Name: Child s age 6/1/17: DOB Grade by 9/1/17 Gender: (check) M F Street Address City State Zip T-shirt size: (circle) YS YM YL AS AM AL (cannot guarantee size after 5/15/2017) Student/CRWC Member: (circle) YES NO University Status: (circle) Faculty Staff Student Alumni Other: PARENT/GUARDIAN INFORMATION Parent/Guardian 1: Last Name First Name Address City State Zip Cell Phone Alternate Phone Parent/Guardian 2: Last Name First Name Address City State Zip Cell Phone Alternate Phone Child resides with: (NAME OF PARENT OR BOTH): Who should we contact first? Parent 1 Parent 2 Other: EMERGENCY CONTACTS Contact 1: Last Name First Name Address City State Zip Cell Phone Alternate Phone Contact 2: Last Name First Name Address City State Zip Cell Phone Alternate Phone

2 MEDICAL INFORMATION Physician Name: Phone: Hospital/Practice Name: Phone: Is your child on any medications that need to be administered during the day? No Yes If yes, please provide information what medications need to be administered during the day? If yes, please provide information for who will be administering medications during the day? Are there any medical conditions our camp staff needs to be aware of? No Yes If yes, please list medical needs: If your child has any known food allergies, please list them: CAMPER RELEASE AUTHORIZATION Campus Recreation Summer Day Camp staff will not release your child to anyone not listed, regardless of relationship to child except a guardian, emergency contact, or any of the following people: If specific individuals are not permitted to pick up your child, please attach appropriate documentation: Name: Relationship Name: Relationship SPECIAL NEEDS Please describe any additional information you would like to share regarding your child that may assist us in caring for them:

3 RELEASE, INDEMNIFICATION, AND HOLD HARMLESS AGREEMENT As the parent/guardian of the above referenced camper, I am fully aware of the recreation activities that my child could participate in while attending camp including rock climbing, swimming, and indoor/outdoor activities. I hereby acknowledge and accept all risks to my child s health and of injury or death that may result from such participation. I agree to release, indemnify, and hold harmless the University of Houston and the University of Houston System, and their governing boards, officers, employees, faculty members, representatives, and agents from liability for the injury of death of my child; or damage to any property that may result from activities pertaining to camp, including, but not limited to those listed above, whether caused by the negligence of the University or otherwise. Should my child require emergency medical treatment as a result of an accident or illness arising from camp, I consent to such treatment. I acknowledge that the University does not provide health and accident insurance for participants and I agree to be financially responsible for any medical bills incurred as a result. I represent that my child is physically and mentally able, with or without accommodations to participate in all aspects of camp. Prior to my child s attendance at camp, I will notify the Department of Campus Recreation in writing if my child has medical conditions about which emergency medical personnel should be informed Signature Date PARENT APPROVAL FOR PARTICIPATION I approve my child to participate in the following activities: (Please initial next to each activity) Please initial Swimming (passed swim test of lifejacket required regardless of age or size) Please initial Rock Wall activities - climbing Please initial Go to the Student Center Games Room bowling alley and arcade Please initial Watch movies during lunch time (movies will be G and PG rated children s films) Please initial Participate in special events hosted by the CRWC, including, but not limited to: Snow cone day, Pizza day, movie days)* Please initial My child can eat food provided by the camp, including, but not limited to: snow cones, pizza, popcorn, s mores, small amounts of candy/sweets* *parents will be notified about weekly events through or by flyer on Mondays. I understand that my child needs to bring the following to camp on a daily basis: (Please initial next to each activity) Please initial I have reviewed and am familiar with the Cougar Cub Camp Parent s Guide Please initial Closed-toed, athletic shoes provided on the UH Campus Recreation website. Please initial Lunch from home (no refrigerator/microwave provided) Please initial Swimming attire: bathing suit, towel, sandals/flip flops, sunglasses, hats, Sunscreen, swim shirt or covering.

4 REFUND AND RELEASE FORM Absences: Refunds are not available for vacations, special events, short-term illnesses of four days or fewer, or other personal commitments that prevent attendance. Refunds for long term illnesses or family emergency of five days or more will be handled on a case by case basis. Refunds: All refund requests must be submitted in writing and received by UH Camp Administration by the dates below: Refund Amount Request must be received 100% April 14 th by 5pm 75% Between April 15 th -May 12 th by 5pm 50% After May 12 th and no later than 15 business days before purchased session begins 25% Within 15 business days of purchased session 0% No refund after the first Monday of session or week Camps Fees paid by credit card will be credited immediately upon approval by UH Camp Administration. Purchases made by check or cash will be refunded by direct deposit within four to six weeks after approval by UH Camp Administration. Refunds will be made only to original payee or credit card holder. Dismissal: On occasion, dismissal may be necessary for disciplinary reasons. This action will take effect only after consultation among the parents, camper (if appropriate) and the camp director. If a camper is dismissed for disciplinary reasons, there will be NO REFUND for the unused days. Mandated Reporting: University of Houston Campus Recreation employees are mandated, by Texas State Law, to report any suspected cases of child abuse or neglect directly to the appropriate authorities for investigation. While we have established internal procedures to facilitate reporting and apprise supervisors, we cannot by law require our employees to disclose his or her identity to anyone. Photo Release: I grant University of Houston, Department of Campus Recreation, or their authorized agent, the irrevocable right to use photographs of my child for informational, publicity, or promotional purposes without prior notification. No names or other personal information will be used. I understand these photographs may appear in printed materials, on the University s web site, in University presentations or exhibits, in newspapers or magazines, or on television. I agree to hold the University harmless from all claims related to the University or its agents use of these photographs for these purposes. I also agree that the University is under no obligation to me or any other party to use these photographs. I acknowledge that I have read and understand the above policies and accept their conditions. I am the parent or legal guardian of the minor, and I am signing on behalf of said minor. Print Name of Parent/Guardian: Signature of Parent/Guardian Date: Date: Date:

5 Child s Name: Child s age by camp: Sex: M F Please check membership status: CRWC Member NON-CRWC Member Community Week FULL PAYMENT due at time of REGISTRATION Please check for EARLY BIRD REGISTRATION (One child / Multi-child discount rate) Will Attend (Please check) UH CRWC Member Fee UH NON CRWC Member Fee Community Extended Care (Extra $35) Week 1: June 5-9 $137 / $ $162 / $ $187 / $ Week 2: June $137 / $ $162 / $ $187 / $ Week 3: June $137 / $ $162 / $ $187 / $ Week 4: June 26 June 30 $137 / $ $162 / $ $187 / $ Week 5: July $137 / $ $162 / $ $187 / $ Week 6: July $137 / $ $162 / $ $187 / $ Week 7: July $137 / $ $162 / $ $187 / $ Week 8: July 31 August 4 $137 / $ $162 / $ $187 / $ Week Please check for LATE REGISTRATON AFTER APRIL 14th (One child / Multi-child discount rate) Will Attend (Please check) UH CRWC Member Fee UH Non CRWC Member Fee Community Extended Care (Extra $35) Week 1: June 5-9 $162 / $ $187 / $ $212 / $ Week 2: June $162 / $ $187 / $ $212 / $ Week 3: June $162 / $ $187 / $ $212 / $ Week 4: June 26 June 30 $162 / $ $187 / $ $212 / $ Week 5: July $162 / $ $187 / $ $212 / $ Week 6: July $162 / $ $187 / $ $212 / $ Week 7: July $162 / $ $187 / $ $212 / $ Week 8: July 31 August 4 $162 / $ $187 / $ $212 / $ PAYMENTS Amount of Payment: Cash Check: # Credit Card (Visa or MasterCard only) For credit cards, Camp Administration will call for credit card information