Elite Athlete Strength and Conditioning Camp For your child s safety, and in order to be permitted to participate in all activities, please fill out this form and return it to St. Michael s Summer Camps as soon as possible. Please note that a physical exam by your doctor is not required. Please remember that being as detailed as possible and providing full disclosure allows us to adequately care for your child. Personal Information: Camper Name: Date of Birth: Height: Weight: July 4 - August 12 (6 weeks) 6 weeks: $1800 4-5 weeks: $325 per week 2-3 weeks: $375 per week Which sport are you training for? Current School (optional): Address: *there will be no training camp on August 1, 2016 6 weeks = $ 1800 4-5 weeks: $325 x _ = $ 2-3 weeks: $375 x _ = $ Total: = $ City: Province: Postal Code: Parent/Guardian Name: Work Number: Cell Number: Email: Parent/Guardian Name: Work Number: Cell Number: Email: Emergency Contact Information: Emergency Contact Name: Relationship to camper: Work Number: Cell Number: Family Physician Name: Phone Number: OHIP#: Health Insurance #: please send photocopy of insurance if applicable
DISCLAIMER: St. Michael s Sports Academy reserves the right to refuse an enrollment or dismiss a camper if it is in the best interest of the Camper and/or the Camp. There will be no refund of any part of the camp fee if a camper is dismissed for infractions due to alcohol, drugs, tobacco or inappropriate behaviour. Camp rules in these areas will be sent to all parents prior to camp starting. We regret we cannot be responsible for any loss or damage to camper s belongings. I desire my child to participate in the full camp program and all activities, unless I advise you otherwise in writing. I agree that having taken such precautions as in your discretion are deemed advisable; you shall not be held responsible for any sickness or accident to my child. Parents are therefore reminded to see that their son/daughter is covered under one of their own Sickness and Accident Insurance plans available at minimum cost throughout the year. If for any reason my child requires medical attention beyond that furnished by the camp, I agree to be responsible for any expenses incurred. Parent/Guardian Name Signature of Parent/Guardian Date Camp Fee: This includes supervision and athletic activities scheduled throughout the week. Campers are required to bring their own food/snacks each day. Campers are also responsible for their own transportation to and from camp. St. Michael s College School is located above St. Clair West Station, so it is TTC accessible, otherwise athletes can be dropped off in the School s parking lot. BALANCE OF FEE IS DUE WITH APPLICATION CHEQUES CAN BE POST-DATED MAY 31 CANCELLATION POLICY: Cancellations after May 31 will be subject to a $50 cancellation fee. NO REFUND will be given for cancellations occurring less than 15 days prior to registered camp session(s). APPLICATIONS WILL BE ACCEPTED AT ANY TIME IF SPACE IS AVAILABLE CAMP INFORMATION PACKAGE WILL BE SENT OUT IN MAY. Finalized group training times will be sent out in June. All athletes should be available for possible training times between Monday Friday, 8:30 a.m. 4 p.m.
MEDICAL INFORMATION FORM Name: Health Card #: Date of Birth: Ht: Wt: Does your child have any of the following conditions? Epilepsy/Seizures ( ) Yes ( ) No Motion Sickness ( ) Yes ( ) No Diabetes ( ) Yes ( ) No Hemophilia ( ) Yes ( ) No / Bleeding Disorders Medication or Medical ( ) Yes ( ) No Asthma / ( ) Yes ( ) No Devices Wheezing (Specify) Heart ( ) Yes ( ) No Disease Muscular/Skeletal ( ) Yes ( ) No Allergies ( ) Yes ( ) No Problems (Specify) Any other condition which might possibly require treatment during the activity? Yes No If yes, please specify: Is your child currently being treated for any illness? Yes No If yes, please specify: Are there any foods your child cannot eat? Yes No If yes, please specify: Parent/Guardian Name Signature of Parent/Guardian Date
Indicate medical issues for which your child has been treated: Epilepsy Debilitating Sports Injury Thyroid Disease Diabetes Heart Problems Migraine Headaches Asthma Nosebleeds Concussions Bleeding Problems Urinary Tract Infections Other significant medical problems requiring full awareness of instructor/camp staff Immunization: Diphtheria Pertussis Polio Measles Tetanus Allergies: None Nuts Bee Stings Medications Other Epi-Pen Required:* Yes No *If anaphylactic camper is required to bring 2 Epi-Pens with them. Please provide detailed reaction to all triggers/reactions in the space provided below. Please provide details of all reactions, and major recent illnesses, operations, injuries or treatments. Give details of any other physical, social or emotional issue for which treatment may be necessary at camp. Please list all regular medications as well as non-prescription medications you or your child is bringing on the trip. Please attach a separate page if necessary. Be sure to provide detailed information regarding the severity and frequency of allergic reactions. IT IS IMPORTANT THAT YOU PROVIDE AS MUCH DETAIL AS POSSIBLE ON ALLERGIES, TRIGGERS, THE SEVERITY OF THE LAST REACTION AND WHAT KIND OF TREATMENT WILL HELP. To the best of my knowledge, (camper s name) is in good health, free from communicable diseases, and physically able to participate in at St. Michael s Summer Camp activities, except as noted above for medical reasons only. In case of medical and/or surgical emergency, if I am not available for consultation, I hereby give permission to the physician, instructors & nurse selected by the camp director or lead facilitator, to secure proper treatment (i.e. hospitalization, injections, transfusions, anesthesia or surgery as appropriately required) for the person as named above. I certify that the above information is accurate, and that I concur with the statement as described. Parent/Guardian Name Signature of Parent/Guardian Date
SPORTS CAMP ACTIVITY PARENT CONSENT, WAIVER OF LIABILITY, INDEMNITY AND MEDICAL RELEASE WARNING: BY SIGNING THIS DOCUMENT YOU AND YOUR CHILD WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE PLEASE READ CAREFULLY Camp participant s name: Activity: Camp Dates & Times: Location: Is Medical information required? Yes No If yes, please complete and attach medical information form. PARENT CONSENT / LIABILITY W AIVER / INDEMNITY / MEDICAL RELEASE 1. As the parent(s)/guardian(s) of, I/we hereby acknowledge that the risk of injury, including serious debilitating injury is involved in athletic participation. I/we recognize that St. Michael s College School and its representatives make efforts to reduce these risks, but further recognize that their efforts cannot and will not eliminate all such risks. I/we am aware of the risks involved, and give my/our consent for the above named camper to participate in all activities associated with _ [describe sports activity] (the Activity ). I/we hereby release, waive, discharge St. Michael s College School, its board of directors, officers, trustees, members, servants, agents, volunteers and/or employees (the Releases ) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage or injury, including death, that may be sustained by my/our child or to any property belonging to my/our child or me/us, whether caused by the negligence of the Releasees or otherwise, while travelling to/from the Activity, while participating in the same or while in or upon the premises where the Activity is being conducted. 2. I/we further agree personally and on behalf of my/our child to defend, indemnify and hold harmless, the Releasees, for any property damages or personal injury caused by my/our child whether individually or in concert with any other person or entity and while participating in the Activity. Payment for any damages which occur will be solely the responsibility of the involved child and their parents or legal guardians. 3. I/we further hereby agree, personally and on behalf of my/our child, to defend, indemnify and hold harmless the Releasees against any and all claims, demands, and actions, causes of action, including all costs and legal fees, for any losses or damages which may be claimed or recovered against or from the Releasees, arising out of or related to any loss, damage, or injury, including death, which is in any connected or associated with my/our child s participation in the Activity, whether caused by the negligence of the Releasees, or otherwise.
4. I/we have read all the information in regards to the Activity. I/we am aware of guidelines of the Activity. 5. I/we am fully aware of the risks and hazards connected with participating in the Activity and hereby allow my/our child to voluntarily participate in said Activity, knowing that the Activity may be hazardous to my/our child and property of my/our child. I/WE VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY, DAMAGE OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by my/our child, or any loss or damage to property owned by my/our child, as a result of being engaged in such Activity, whether caused by the negligence of Releasees or otherwise. 6. In the event of a medical emergency, a representative of St. Michael s College School will attempt to contact me/us at the emergency contact number(s) I/we have provided below. However, should St. Michael s College School be unable to contact me/us, or if medical circumstances require, I/we hereby grant permission to the Releasees to provide first aid treatment and to arrange for any appropriately qualified health care professional to give any and all medically appropriate emergency care to my/our child including, but not limited to, anesthesia and surgery. I/we also hereby release, waive and discharge the Releasees from any claim whatsoever, which arises or may later arise as a result of any first aid treatment rendered by the Releasees to my/our child. 7. I/we assume full responsibility and liability for any and all expenses, damages, accidents, illnesses, injuries or medical expenses of and to my/our child or our property resulting from such participation. I/we attest and affirm that the participant has no limitation that should prevent participation in the Activity and I/we have not been advised or informed by anyone to the contrary. I/we am aware that St. Michael s College School does not carry medical, dental, accident or disability insurance for participants and that it is the responsibility of the parent(s)/guardian(s) to obtain any insurance coverage that may be required in this regard. 8. I/we further agree to inform the appropriate school official(s) should my/our child s physical condition change in any way and any time so as to affect his participation in the Activity herein named. This agreement shall also be effective and binding upon my/our heirs, next of kin, executors, administrators, assigns and representatives in the event of my/our death or incapacity. Name Signature Date Parent/Legal Guardian Parent/Legal Guardian Address City Province Postal Code Home telephone Work telephone Emergency Contact Number