ANTEATER RECREATION SUMMER CAMP

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Sherman James
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1 ANTEATER RECREATION SUMMER CAMP COMPLETING YOUR WAIVER FORMS All forms have the ability to be completed through Adobe Acrobat. At this time, the University still requires inked (not electronic) signatures. You may type in all information into the registration documents, once the forms are completed, please print out the forms and sign each signature requirement. Once the forms are completed, you can deliver them through an option below. All forms must be received by the Anteater Recreation Center at UC Irvine, at least 1 week (7 days) prior to the start of camp. Camp Date: Waiver Forms Due: June 18, 2018 June 11, 2018 June 25, 2018 June 19, 2018 July 9, 2018 July 2, 2018 July 16, 2018 July 9, 2018 July 23, 2018 July 16, 2018 July 30, 2018 July 23, 2018 August 6, 2018 July 30, 2018 Forms may be delivered in the following ways: By (Preferred): Scan or take photos of completed forms (with inked signatures) and send to: In Person: Please put forms in an envelope/packet with ATTN: Anteater Recreation Summer Camps on the front. Forms can be accepted by Service Desk (located upstairs from the ARC Front Desk) personnel, Monday Friday from 8am 6pm. Forms delivered outside of this time can be dropped off at the Front Desk. Please make sure the attendant knows it is for ARC Summer Camps. By Mail to: Campus Recreation Services 680 California Ave Irvine, CA By Fax: Please include a cover page with Attn: ARC Summer Camps (949) Receiving your forms: Once your forms have been received, you will be notified by that your registration is complete by an ARC Summer Camp staff member. Registration is not considered complete until all forms have been completed and received (with confirmation ) by the Anteater Recreation Center. If you do not receive a confirmation within 2 business days of sending in your forms, please contact Kim Anderson at k.anderson@uci.edu. Forms not received 2 weeks (14 days) prior to the start of camp will be notified by that the deadline to turn in forms is in 1 week (7 days). If forms are not received 1 week (7 days) prior to the start of camp, your child may be dropped from the camp.

2 University of California, Irvine Campus Recreation YOUTH CAMP REGISTRATION Print Legibly ENROLLMENT Please fill out one form per child Camp Dates / Time Fee PERSONAL INFORMATION Child s First Name: Last: M.I.: Age: Birth date: MM/DD/YYYY T shirt size(pick one): Youth SM, Youth MD, Youth LG, Adult SM, Adult MD, Adult LG Gender: Male Female Parent/Guardian First Name: Last: Address: City: State: Zip: Parent/Guardian Day Phone: Cell Phone: Emergency Contact First Name: Last: Day Phone : Cell Phone: Relationship: AUTHORTIZED CAMPER PICK UP/DROP OFF (Please list those other than Parent/Guardian and Emergency Contact) CAMPER SELF SIGN OUT AUTHORIZATION (I authorize my camper, who is at least 12 years old, to sign themselves in and out of camp) Parent/Guardian Authorization Signature: How did you hear about us: Returning camper ARC website UCI Zot Friend Other: Payment Information Amount enclosed: Date: Cash Check #: Credit Card: Visa Mastercard Credit Card#: Exp Date: FOR OFFICE USE ONLY Fee: Cash Check # Visa MasterCard Verified by: Date:

3 University of California, Irvine Campus Recreation Consent to Photograph I authorize the University of California, Irvine (UC Irvine) to capture the name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements, or to permit others to do so, of (Name of Individual) for use by UCI Campus Recreation and the Anteater Recreation Center in printed or electronic marketing and promotional materials, including the UCI Campus Recreation website and social media. I waive and release the University of California and its officers, agents and employees, from any claim or liability relating to the use of my name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements. I acknowledge that the University of California will rely on this consent and release in producing, broadcasting, and distributing materials containing my name, likeness, identity, voice, photographic image, videographic image or oral or recorded statements, and that I will receive no money or remuneration of any kind from the University of California related to this consent and release or the materials covered by this consent and release. I am an adult, 18 years or older, and I have read and understand this agreement and I freely and knowingly give my consent to the University of California as described herein. Signature of Individual (or of parent or guardian if individual is a minor) Relationship (if other than individual) Date *Authorization required for camp group photo

UC Irvine Campus Recreation Youth Programs Medical Consent Form I (we), the undersigned parent(s), or legal guardian of (Name of Child), do hereby request that he/she be permitted to attend the UC

4 UC Irvine Campus Recreation Youth Programs Medical Consent Form I (we), the undersigned parent(s), or legal guardian of (Name of Child), do hereby request that he/she be permitted to attend the UC Irvine Campus Recreation Youth Programs and should the need arise, do hereby authorize and consent to any x ray examination, anesthetic, medical or surgical diagnosis and treatment rendered under the supervision of a licensed physician. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the licensed physician in the exercise of his/her best judgment may deem advisable. It is understood that, if possible, effort shall be made to contact the undersigned prior to rendering treatment but that any of the above treatments will not be withheld if the undersigned cannot be reached in a timely manner. I (we) will not hold liable the Regents of the University of California, its officers, employees, or agents for medical aid or first aid rendered and will be solely responsible for all medical or other expenses incurred in the care of my child. I authorize release of information on this form to any licensed physician, hospital or medical staff member involved in the treatment or care of my child. Parent/Guardian Name (Print): Parent/Guardian Signature: Medical Information: (All medical information is confidential) Does your camper have any allergies? Yes No (Please note, ARC Cooking Camp may not be able to accommodate all allergies) If yes, please list: Does your camper carry an Epi Pen for emergency allergic reactions? Yes No Will your camper need to take prescribed medication during camp? Yes No (Please note, ARC Summer Camp staff are not authorized to administer medication to participants) If yes, please list: Does your camper have any pre existing conditions that we should be aware of? Yes No If yes, please describe: Is there anything else we should be aware of? Insurance Information (Required) Insurance Company Policy Holder Name Policy/Member Number Parent/Guardian Release I am the parent or legal guardian of and I have read and understood and agree to the terms and conditions of this application and I am signing this release on behalf of said minor. Parent/Guardian Signature: Date:

5 Participant s Name: Please Print UNIVERSITY OF CALIFORNIA, IRVINE Campus Recreation and Anteater Recreation Center Youth Camp Waiver of Liability, Assumption of Risk, and Indemnity Agreement Waiver: In consideration of being permitted to participate in any way in Campus Recreation or Anteater Recreation Center Youth Camp Programs. Including but not limited to participating in Archery, Badminton, Cooking, Fencing, Floor Hockey, High Ropes, Rock Climbing, Lacrosse, Athlete Performance, Yoga&Swim and Other Youth Programs or other Dropin Activities, hereinafter called The Activity, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity. Signature of Parent/Guardian of Minor Date Signature of Participant Date Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death. I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks. Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred. Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Signature of Parent/Guardian of Minor Date Signature of Participant Date Participants Age (if minor) Volwaiver 12/14

Camp Code of Conduct Camper Agreement The Anteater Recreation Summer Camp Staff will enforce these rules during camp to ensure the well being, safety and enjoyment of each camper!

6 Camp Code of Conduct Camper Agreement The Anteater Recreation Summer Camp Staff will enforce these rules during camp to ensure the well being, safety and enjoyment of each camper! Please go over these rules with your camper so they are aware before the start of camps. 1. Campers are not allowed to leave the Camp area for any reason without being escorted by a Camp Assistant. 2. All restroom and water break trips will be taken with at least 2 campers and 1 assistant. Assistants are not allowed in restrooms while occupied by campers. 3. Always listen to the Head Coach/Instructors rules during camp. They are in place for your safety and enjoyment of camp! 4. We have a zero tolerance bullying/abuse policy. No name calling or inappropriate language will be allowed. No inappropriate physical contact is permitted. No hitting, kicking, spitting, etc. 5. Possession of any type of weapon will not be permitted. Weapons include knives, guns, pellet guns, BB guns, sling shots, water pistols, or any other kind of device that could inflict injuries to yourself or others. 6. Do not use equipment for anything other than its intended purpose during camp. Equipment may not be used to hit or touch another camper. Equipment must be shared by all campers. 7. Participants who abuse or damage University property will be billed for the cost of the damage. 8. Tell a camp staff member if there is any problem/issue during camp that is making you unhappy. 9. Use the Golden Rule! Treat other campers and camp staff how you would want to be treated! I,, understand that any violation to this code of (Please print camper name) conduct may result in expulsion from the ARC Summer Camp program. Participant s Signature: Date: Parent/Guardian Signature: Date:

Math + Leadership Camp Rancho Minerva Middle School July 11-22, Registration Form

Math + Leadership Camp Rancho Minerva Middle School July 11-22, Registration Form Math + Leadership Camp 2016 @ Rancho Minerva Middle School July 11-22, 2016 Registration Form CONTACT INFORMATION Math for America San Diego Email: sandiego@mathforamerica.org Phone: 858-822-6284 OFFICE