A&M REC ROAD TRIP. August 28/29 Drop Off at 8:30pm at the Atrium of the Woodway Campus Pick up at 7:30 am or after Bible Study on Sunday morning.

Transcription

1 A&M REC ROAD TRIP 7 th and 8 th Graders of 2010 Road Trip to the Student Recreation Center at Texas A&M University August 28/29 Drop Off at 8:30pm at the Atrium of the Woodway Campus Pick up at 7:30 am or after Bible Study on Sunday morning. Student Information: Cost is $40 Includes: Unlimited Access to the Rec Center ALL NIGHT LONG!!! Pizza Free T-shirt Drinks Bus Basketball Indoor and Sand Volleyball Indoor Soccer Swimming & Diving Rock Climbing Racquetball Ping Pong Dodgeball Name: (first & last) Grade: Gender: Address: City: State: Zip: Home Phone: Cell Phone: Payment Type: (circle one) Cash Check Credit Card Credit Card Information: Card Number Name as it appears on card Card Holder s Signature Visa Master Card American Express Discover Expiration Date Billing Zip Code Cardholder s Phone Number Shirt Size (check one) Adult Small Adult Medium Adult Large Adult X-Large Second Baptist Church JHigh Ministry 6400 Woodway Houston, TX Phone:

2 SECOND BAPTIST CHURCH STUDENT MINISTRY Registration and Medical Information Parental Permission and Release (Please Print) Student s Name School Primary Address Father s Name Home Telephone_ Date of Birth Grade Mother s Name Home Telephone Emergency Contacts (Other than Parents) Contact #1 Contact #2 Name Relationship to Child Home Telephone Name Relationship to Child Home Telephone Medical History and Current Information Current Medical Problems Drug Allergies_ Food Allergies Insect Allergies Current Medications Dosage Schedule Parent/Legal Guardian s Signature(s)

3 SECOND BAPTIST CHURCH STUDENT MINISTRY Registration and Medical Information Parental Permission and Release Please indicate if your child has ever had any of the following. If you mark yes to any condition, please explain in detail below including date of diagnosis and current treatment. Yes No Yes No Diabetes/Hypoglycemia Depression/Metal Health Asthma Seizures ADD/ADHD Migraines Explain: Any Special Conditions not listed above: Medical Release I/We,, the parent(s) of do hereby give over and release unto the staff and chaperones of Second Baptist Church of Houston all authority and responsibility to authorize any and all medical treatment necessary for the protection of the health and well-being of my aforementioned child. This authorization shall authorize any and all medical treatment by licensed medical personnel, pursuant to the express authorization, whether written or oral of the above mentioned representatives. This authorization shall be effective on August 28, 2010 through August 29, 2010, inclusive or until it is expressly revoked. I hereby grant permission for the Second Baptist urse or trained designate to administer over-the-counter medications, including but not limited to: Tylenol, Ibuprofen, Pseudophed, Claritin, Tums, Benadryl, Anti-Itch Cream, Delsym, Visine eye drops. I hereby release Second Baptist Church, its staff, chaperones, and volunteers, from any and all claims and liabilities of whatsoever nature, both individually and collectively, that may arise from my child s participation in this event. I/We understand that I/we will be financially responsible for any medical costs incurred in the emergency treatment and/or transportation of my child. Transportation and Property I/We further understand that my child will be transported in equipment owned, leased, or rented by Second Baptist Church. I/We understand that I/we are financially responsible for any damage caused by or in part by my child. This includes all private and public property. Promotional Release Second Baptist Church has my permission to use any photographs/video of the above named child for brochures, videos, advertising, web page, and other promotional items. I/we further understand that these photos/videos will only be used for SBC promotional purposes. Yes or No (Circle One) I/We acknowledge that I/we have read and understand all aspects of both sides of this document. I/We agree that copied representations of our signatures should be accepted as binding. This form must be signed in the presence of a witness. Both parent signatures are preferable, but only one parent signature is required. A copy of your Health Insurance Card must accompany this form for your registration to be complete. Parent/Legal Guardian s Signature(s) Date: / /

4 Participant Name: Semester: PARTICIPANT WAIVER AND HOLD HARMLESS FORM THE TEXAS A&M UNIVERSITY SYSTEM TAMU OUTDOORS INDOOR CLIMBING FACILITY 1. In consideration for receiving permission for myself or my dependent to participate at the Indoor Climbing Facility (herein referred to as ACTIVITY), which is sponsored by the Department of Recreational Sports TAMU Outdoors program at Texas A&M University (herein referred to as SPONSOR), a member of The Texas A&M University System, I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO HOLD HARMLESS for any and all purposes SPONSOR, The Texas A&M University System, the Board of Regents for The Texas A&M University System, and their officers, servants, agents, volunteers, or employees (herein referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, CLAIMS, DEMANDS, OR INJURY, INCLUDING DEATH, that may be sustained by me while participating in such activity, or while on the premises owned or leased by RELEASEES, including injuries sustained as a result of the negligence of RELEASEES. I acknowledge there may be physically strenuous activities. I know of no medical reason why I should not participate. 2. I am fully aware that there are inherent risks involved with ACTIVITY, including but not limited to the following: Paralysis, injury or death while traveling to and from the activity site. Equipment may fail, malfunction or be used incorrectly. Rope burns while handling the rope. Falling to the ground from a height of varying distances. During a fall on top rope or lead, the jolt from the rope catching you may injure you. Objects falling off the climbing site may hit you such as climbing holds, bolts, climbing equipment and even other people. Anchors may fail. Belayer error. Slipping and falling at the climbing site. Personal injury including but not limited to: blisters; sprains, strains, dislocations, torn muscles and/or ligaments; fractured or broken bones; eye damage; cuts, wounds, scrapes, abrasions and/or contusions; head, neck, and/or spinal injuries; medical illnesses; allergic reaction, shock, paralysis or death and serious injury or impairment to other aspects of my body and general health and well being and I choose to voluntarily participate in said activity with full knowledge that said activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me as a result of participating in said activity including injuries sustained as a result of the negligence of RELEASEES. I further agree to indemnify and hold harmless the RELEASEES for any loss, liability, damage or costs, including court costs and attorney s fees that may occur as a result of my participation in said activity.

5 3. I understand that RELEASEES do not maintain any insurance policy covering any circumstance arising from my participation in this activity or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. 4. I give permission for the activity leaders to seek emergency medical, rescue or evacuation services for me should I become injured or ill with the understanding that I am responsible for any expenses incurred. I fully understand that Texas A&M University does NOT provide any medical insurance coverage for me while participating in this activity. I also realize that I may be attended to by the activity leaders until medical care is available. 5. I acknowledge that photographs and video tapes may be taken during the activity and allow reproductions of these photographic materials to be used in promotional activities initiated by TAMU Outdoors, the Department of Recreational Sports and Texas A&M University. 6. It is my express intent that this Covenant Not to Sue and Agreement to Hold Harmless shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be governed by the laws of the State of Texas. 7. In signing this Covenant Not to Sue and Agreement to Hold Harmless, I acknowledge and represent that I have read the foregoing Covenant Not to Sue and Agreement to Hold Harmless, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements apart from the foregoing agreement that has been reduced to writing have been made. I execute this document for full, adequate and complete consideration fully intending to be bound by the same, now and in the future. SIGNED this day of, Participant: Printed Name: FOR DEPENDANTS (if participant is under 18 years old): Legal Printed Name of Parent or Legal Guardian: Signature of Parent or Legal Guardian: Street Address: City State Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( )

6 TAMU OUTDOORS I DOOR CLIMBI G FACILITY CLIMBER I FORMATIO FORM Participant Legal Printed Name Date of Birth ID# or Drivers Lic # Street Address: City State Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Student Fac/Staff Dependant General Public In Case of Emergency, (In the case of a dependent climber, only fill out this portion if the emergency contact is different from the guardian information found on page 2) Contact Name: Relationship: Street Address: City State Zip Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Use of Indoor Climbing Facility Risks and Hazards There are risks and hazards inherent to climbing and bouldering. The same elements that contribute to the uniqueness and fun of these activities can cause loss or damage to equipment, injury, illness, or in extreme cases, permanent trauma or death. TAMU Outdoors does not want to heighten or reduce your enthusiasm for the experience, but we do want you to know in advance what to expect and to be informed of some of the possible risks. Participant initials, acknowledging inherent risks of the indoor climbing facility listed above under item #2.