OHIO CAMPus REC Summer Camp AGREEMENT AND RELEASE OF LIABILITY FORM This release executed by the Undersigned on behalf of [Name of Participant] with an address at ( Participant ) to Ohio University, Athens, Ohio (the University ). The term, Undersigned, is used in this Agreement as pertaining to: (i) if Participant is of majority age, it refers only to Participant; (ii) if Participant is not of majority age, Undersigned refers to Participant and Participant s Parent or Guardian. The term Program Director, is used in this Agreement pertaining to the University employee leading the Program. In consideration of Ohio University through its Campus Recreation department organizing and operating a summer camp program and making it available for participation by Participant and others, the Undersigned agrees as follows: 1. Participant wishes to participate in the University s CAMPus REC Summer Camp in Athens, Ohio from June 4th, 2018 through August 17th, 2018 ( Program ). 2. The University agrees to provide a Program Director to serve as the representative of the University. 3. The Undersigned acknowledges that the Participant will participate in activities both on and off of University s Athens campus including, but not limited to: dodgeball, crafts, swimming, volleyball, climbing wall, soccer, cardiovascular exercise, etc. Activities involve strenuous exertions of strength using various muscle groups, some involve quick movements using speed and change of direction, some involve other participants or instructors, and others involve sustained physical activity that places stress on the cardiovascular system. The specific risks vary from one activity to another, but the risks range from: minor injuries such as scratches, bruises and sprains; to major injuries such a broken/fractured bone, eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; to catastrophic injuries including paralysis and death. The Undersigned understands and agrees that the University, its governing board, employees, and agents: (i) are not responsible or liable for any injury, damage, loss, accident, delay or other irregularity which may be caused by the defect of any vehicle or the negligence or default of any company or person engaged in providing or performing any of the services involved in this Program; (ii) are not responsible for losses or expenses due to sickness, weather, strikes, hostilities, wars, natural disasters, or other such causes; (iii) are not responsible for any disruption of travel arrangements, or any consequent additional expenses that may be incurred therein; (iv) assume no liability whatsoever for any loss, damages, destruction or theft or the like to Participant s luggage or personal belongings and that Participant has retained adequate insurance or has sufficient funds to replace such belongings and the Undersigned will hold the University harmless therefrom. 4. Knowing the dangers, hazards, and risks of such activities, and in consideration of being permitted to participate in the Program, the Undersigned, on behalf of Participant's family, heirs, and personal representative(s), agrees to assume all the risks and responsibilities surrounding Participant's participation in the Program, the transportation, and in any activities undertaken as an adjunct thereto, and in advance releases, forever discharges, waives, and covenants not to sue the University, its governing board, officers, agents, employees, and any students acting as employees ( the University and its Agents ), from and against any and all liability for any harm, injury, damage, claims, demands, actions, causes of action, costs, and expenses of any nature whatsoever which Participant may have or which may hereafter accrue to the Undersigned, arising out of or related to any loss, damage, or injury, including but not limited to suffering and death, that may be sustained by Participant or by any property belonging to Participant, whether caused by the negligence or carelessness of the University and its Agents, or otherwise, while in, on, upon, or in transit to or from the Program or any activity adjunct to the Program. 5. The Undersigned assures the University of Participant having consulted with a medical doctor with regard to Participant's personal medical needs such that the Undersigned can and does further state that there are no health-related reasons or problems which preclude or restrict Participant's participation in this Program. The Undersigned is aware of all applicable personal medical needs of Participant and will meet any and all needs for payment of hospital costs while Participant is undertaking this Program and that the Undersigned hereby grants the University and its agents full authority to take whatever actions they may consider to be warranted under the circumstances regarding Participant s (or Participant s baby if born during the Program) health and safety if the Participant is unconscious or otherwise unable to do so her/himself, and fully releases the University and its Agents for any liability for such decisions or actions or expenses as may be taken in connection therewith. The Undersigned authorizes the University and its Agents, at their discretion, to place Participant at the Undersigned s expense, and without further consent by Participant or the Undersigned, in a hospital for medical services and treatment. The Undersigned hereby releases the University and its Agents from all medical and transportation expenses incurred on behalf of or for the benefit of Participant.
6. The Participant agrees to participate fully in the schedule of the Program. 7. Participant hereby recognizes that the Program and attendant activities are group endeavors and agrees to accept and abide by the University and its agents, or the will of the majority whenever a matter of choice is presented to the group. Participant acknowledges that the University reserves the right to cancel, without penalty, the offering and conduct of the Program and the right to make any alterations, deletions or modifications in the schedule or academic program as deemed necessary by the University or its representative. Participant is not permitted to separate from the group. If Participant breaks the schedule and leaves group, he/she does so at his/her own risk and University will bear no responsibility to Participant or the Undersigned. 8. The Participant agrees to respect and abide by the laws in Athens, Ohio and any other location traveled. Participant agrees to review in advance of the Program, respect and abide by University s Student Code of Conduct which is incorporated herein and can be found at https://www.ohio.edu/communitystandards/upload/ohio-university-student-code-of-conduct-through- 081815-2.pdf in addition to any other rules provided to the participants at the Program, written or oral. The Participant further agrees to accept corrective actions up to and including termination of participation in the Program if Participant s conduct is determined to be detrimental to the best interest of the Participant, the Program or University. Participant acknowledges and agrees that he/she may be required to leave the Program at the sole discretion of the Program Director. The Participant also may be required to leave the Program for medical reasons. If asked to leave, the Undersigned agrees to take immediate action to travel to the University and to take Participant from campus or to make arrangements for the Participant to immediately and safely leave campus. 9. The Undersigned further agrees that this Agreement shall be construed in accordance with the laws of the State of Ohio, which shall be the forum for any lawsuits filed under or incident to this Agreement or the Program. The term and provisions of this Agreement shall be severable, such that if a court of competent jurisdiction holds any term to be illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby. THIS IS A RELEASE OF LEGAL RIGHTS. READ BEFORE SIGNING. IF PARTICIPANT IS A MINOR UNDER THE AGE OF 18 YEARS OLD, A PARENT OR LEGAL GUARDIAN MUST SIGN BELOW. Participant Signature Date As a parent/guardian on behalf of the above-named minor, I have read the above Agreement and Release of Liability Form and I understand and agree to the terms and conditions stated herein. I further indemnify Ohio University, its agents, officers and employees against any action brought against Ohio University, its Board of Trustees, agents, officers, and employees, and student volunteers by the above-named Participant, including but not limited to an action brought by him or her upon reaching the age of majority. I warrant that I am authorized to execute this document on behalf of the above-named minor. Parent/Guardian Signature Date Minor s Date of Birth For Office Use Only: Date of Activity + 3 Years = Date of Destruction Date Child Turns 18 + 3 Years = Date of Destruction (For Minors)
Refund & Release Form (One for Each Camper) 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: There will be no refunds for deposits. Refund request must submitted by Wednesday prior to the start of the session. Refunds will be credited to a future week if possible. Dismissal: There are times when the camp must dismiss a child due to illness, psychological, emotional or physical disability that precludes the child from participating safely or effectively in a group. Dismissal will take effect only after consultation among the parents, camper (if appropriate) and the camp director. Dismissal for the aforementioned reasons will result in a complete refund for the unused days. 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: Ohio University Campus Recreation employees are mandated, by Ohio 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. 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
Behavior Expectations (One for Each Camper) The Camp Staff and Administration provides children with guidelines for appropriate behavior and rules to follow while enrolled at camp. We encourage positive actions through positive reinforcement and close supervision. Our main goal is to keep the children safely involved in activities so the inappropriate behavior is limited. The following steps are followed if inappropriate behavior occurs. Special modifications may be made to adapt to a child s needs. 1. The child is spoken to privately in a firm but gentle manner regarding the unacceptable behavior. 2. If the said behavior continues, the child is removed from the activity for a cool down/timeout until both the counselor and the child feel the child is ready to return. 3. If the said behavior still continues, the child s parent will be called or spoken with before departing for the day. 4. A Behavior Report will be filed any time a child receives a cool down/time out. 5. Three behavior reports during your child s stay at camp may result in termination of service from camp. 6. An Incident Report will be filed when there is evidence of property destruction, injury to an individual, physically touching an individual, accrual of multiple behavior reports, and other inappropriate behavior is grounds for dismissal from camp. 7. A child may be terminated from camp without prior notice to the parents under the following conditions: a. A child injures another individual, resulting in the need for medical attention. b. A child displays violent, uncontrollable behavior that will put others in the program at risk. ** A child terminated from a session will not be able to participate in camp for the remainder of the year. ** Behavior incidents will never be dealt with in a demoralizing, humiliating, or abusive manner. No child shall be subject to abuses of neglect, cruel, unusual, severe, or corporal punishment including: punishments which subject a child to verbal abuse, ridicule, humiliation, denial of food, use of bathroom facilities, punishment for soiling, wetting, or not using the toilet. ** Staff members shall not be subject to verbal or physical abuse by a child enrolled in camp, or by their parent, including but not limited to: cruelty, humiliation, foul language, and ridicule. Print Child s Name Print Parent/Guardian s Name Signature Date
PARTICIPANT S MEDICAL INFORMATION Ohio University requests this information so that our Program staff can properly plan to meet the needs of Participant and if there is an emergency, to have accurate information to provide and/or seek treatment for Participant. Participant Name/Date of Birth: Physician/Address/Phone: Dentist/Address/Phone: Does the Participant have any illness, special conditions, activity limitations, asthma, allergies (including food), etc. that the Program staff should be aware of? Yes No Is the Participant currently taking any medications that we should be aware of including side effects? Yes No Is the Participant taking any medications that must be administered during the Program? Yes No If yes, you must also complete the Authorization for Medication Administration form. Does the Participant have any relevant medical history that we should be aware of? Yes No Does the Participant need any accommodations to safety participate in the Program? Yes No Does the Participant have any limitations for attending field trips, if applicable? Yes No If the Participant has any other medical conditions or special needs that you think it is important for Program staff to be aware of, please identify and explain here: EMERGENCY MEDICAL CONSENT To the best of my knowledge, my child, the Participant, is capable of participating safely in the Program and that any activity restrictions, allergies, and medications are listed on this form. I give permission to Program staff to provide routine first aid care and in the event of serious illness or injury, I give Program staff permission to seek and authorize emergency medical treatment. I hold harmless and agree to indemnify the Program and Ohio University from any claims, causes of action, damages and/or liabilities arising out of or resulting from said medical treatment. I further agree to accept full responsibility for any and all expenses, including medical and transportation expenses that may derive from any injuries to my child that may incur during his/her participation in this Program. I understand and acknowledge that my failure to disclose relevant information may result in harm to Participant and/or others during this Program. By signing my name, I represent that I have provided all materials and important information to the Program pertaining to Participant s medical, mental and physical condition and that it is accurate and complete. I agree to notify the Program of any changes in my mental, physical or medical condition before the Program begins. Parent/Guardian Name/Address/Phone: Signature: Date:
Parent/Guardian #1 First Name Last Name Home Address Daytime Address (i.e. work) Home Phone Daytime Phone Other Phone Email Address Parent/Guardian #2 First Name Last Name Home Address Daytime Address (i.e. work) Home Phone Daytime Phone Other Phone Email Address Camper Pick-up Authorization My child should be kept at the Summer Day Camp until he/she is picked up AND signed out by one of the parents/guardians or other designated individual listed below. The person picking up your child will be asked to show a government issued photo ID (driver s license, ID card, current Passport, etc.). Parent/Guardian(s) must list themselves in addition to any other authorized individual. Only those listed below will permitted to pick up your child. Campus Recreation Summer Day Camp staff will not release your child to anyone not listed, regardless of relationship to child. If specific individuals are not permitted to pick up your child, please attach appropriate documentation. 1. Phone 2. Phone 3. Phone 4. Phone 5. Phone 6. Phone
AUTHORIZATION FOR MEDICATION ADMINISTRATION Only complete this form if the Participant requires medication to be given at Ohio University Participant Name: Date of Birth / / 1. I hereby give my permission for authorized Program personnel to administer the below medication as directed by our physician. 2. I will send the medication to Ohio University in the original container in which it was dispensed by the doctor or pharmacist. 3. I agree to notify the Program staff immediately if there is any change to the information below. 4. I release and agree to hold Ohio University, its governing board, officers, agents, employees, and any students acting as employees harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization. Parent/Guardian Signature Address Printed Name Cell Phone Work Phone Physician s orders for the administration of medication by Program staff Program: Participant s name is under my care and should receive the following medications while at the Medication Dosage Time Schedule Reason for medication(s): Any possible side effects: Special Instructions: Licensed Physician Signature Address Printed Name Phone