Camp $tartup Registration Form v0514

REGISTRATION FORM
July 14 – 18, 2014 | 9am – 4pm
Student’s Name
LAST
FIRST
Date of Birth
Fall 2014 Grade Level
School Attending Fall 2014
Student’s Email Address
Parent’s Name
Parent’s Email Address
Parent’s Work Phone
Home Phone
Parent’s Cell Phone
Preferred Contact:  Work  Home  Cell
Home Address
STREET
CITY
ZIP
Emergency Information: If we cannot reach parent, call:
Name
Phone
Relationship
To Register, submit the following:
1. Complete this Camp Registration Form and submit with a completed Waiver of Liability and
Release Agreement, Medical Information Form, and Media Release Form. Forms must be
submitted for each camp participant.
2. Submit payment either by check or credit card. Registration is $245 per student. If paying by
credit card, complete the form and fax to (303) 755-7363 or mail to the CBCC Youth Initiative.
If sending check, make checks payable to:
CBCC Youth Initiative
2851 S Parker Road, Ste. 560
Aurora, CO 80014
Visa and Mastercard Only.
PRINT Cardholder’s Name:
Card Number:
Exp. Date:
Sec. Code:
Cardholder’s Signature:
NOTE: Cancellation/Refund Policy – Cancellations must be submitted by July 1, 2014. There is a non-refundable
cancellation fee of $100 to cover program administration costs.
MEDICAL INFORMATION AND RELEASE FORM
Name
Date of Birth
Address
Home Phone
City
Zip
Cellphone
In Emergency, Notify
Family Doctor
Grade Fall 2014
Email
Phone
Phone
Date of Last Physical
HEALTH HISTORY Check all that apply:
¨ Drug Allergies
¨ Asthma
¨ Physical Handicap
¨ Food Allergies
¨ Seizure Disorder
¨ Stomach Problems
¨ Environmental Allergies
¨ Diabetes
¨ Other
¨ Heart Condition
¨ Behavior/Nervous Disorder
If any of the above are checked, please give details (i.e. include normal treatment of allergic reactions, etc.)
Date of last tetanus shot
Name, dosage, and frequency of any medications that must be taken regularly or as needed:
Any activity restrictions? ¨ Yes ¨ No What restrictions?
Medical Insurance: Your carrier will be billed for medical charges in case of an accident or illness while at camp. Do
you have medical insurance? ¨ Yes ¨ No
Insurance Company
Policy Number
MEDICAL RELEASE
In the event I cannot be reached in an emergency during the camp dates as shown on this form, I hereby give my
permission to the physician or dentist selected by the camp staff to hospitalize, secure proper treatment, and/or order an
injection, anesthesia, or surgery for my child as deemed necessary. I also authorize the first aid attendant on duty at Camp
$tartup to administer medical aid as required for illness or injury under a physician’s orders. The signature of the parent
or guardian below is intended to serve as a medical release.
Parent/Guardian Signature
Print Name
Relationship to Child
Spouse’s Name
Date
WAIVER OF LIABILITY AND RELEASE AGREEMENT
I, ____________________ , (parent/guardian), for myself, any other parent and the participant,
in connection with my son/daughter, ________________ (“the participant”), attending and
participating in the CBCC Youth Initiative’s Camp $tartup (hereafter referred to as “Camp
$tartup”), hereby agree as follows:
ACKNOWLEDGEMENT OF RISKS
The Undersigned understands that there are certain dangers, hazards and risks (foreseen and
unforeseen) inherent in attending and participating in the Camp $tartup, including, without
limitation, risks related to use of equipment and facilities, personal safety (including risks of
minor, serious or mortal personal injury) and risks of property damage.
EXPRESS ASSUMPTION OF RISK AND RESPONSIBILITY
In recognition of the dangers, hazards and risks (foreseen and unforeseen) associated with
attending and participating in the Camp $tartup, the undersigned confirms that the participant is
physically and mentally capable of attendance and participation in all activities and use of all
equipment associated with the Camp $tartup. The participant is willingly and voluntarily
attending and participating and the Undersigned agrees that they and the participant shall assume
all dangers, hazards and risks (foreseen and unforeseen) inherent in, arising from or related to the
participant’s attendance and participation in the Camp $tartup.
PARTICIPANT RESPONSIBILITIES
The Undersigned and the participant agree to the following:
Acceptable Conduct by Participant.
During attendance and participation in the Camp $tartup, which may include travel to and from
the camp location, the participant will act in a responsible manner and will abide by the
instructions of any CBCC or Camp $tartup personnel, and will comply and follow the rules and
regulations of the CBCC Youth Initiative.
Participant's Health; Health Insurance Coverage
In anticipation of the participant's enrollment in the Camp $tartup, the Undersigned and
participant have consulted with a medical doctor with regard to the participant's medical
condition. The participant has no physical or mental conditions which would cause him/her to be
a danger to himself/herself or to others, is capable of participating in all activities associated with
the Camp $tartup and has submitted the required health insurance information and physician’s
report.
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Camp $tartup 2014
Waiver of Liability and Release Agreement
Page 2
WAIVER OF CBCC LIABILTY/RELEASE AND HOLD HARMLESS
In consideration of the attendance and participation in the Camp $tartup, and knowingly the
dangers, hazards and risks (foreseen and unforeseen) of attending and participating in the Camp
$tartup, the Undersigned, for themselves, any other parent and the participant, understand(s) and
agree(s) to RELEASE AND HOLD HARMLESS the CBCC Youth Initiative and its current and
former board members, officers, directors, employees, attorneys, representatives and agents and
waive any claim for injury and damage resulting from the participant’s attendance and
participation in the Camp $tartup.
ACKNOWLEDGEMENT
It is the express intent of the Undersigned that this Agreement shall bind the undersigned, any
other parent, the participant, the participant's family, estate, heirs, administrators, personal
representatives or assigns. The Undersigned acknowledges that they have read and understand this
document and the RELEASE AND HOLD HARMLESS provisions. The Undersigned agrees that
this Agreement shall be construed in accordance with the laws of the State of Colorado, without
giving effect to the conflict of laws provisions thereof, and that the State of Colorado shall be the
forum for any lawsuits filed under or incident to this Agreement. The terms 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, and each and every term and condition of this
Agreement shall be valid and enforced to the fullest extent and in the broadest application
permitted by law.
Parent/Guardian signature: _______________________________ Date:
Parent/Guardian printed name: _____________________________________
Emergency Phone #: _____________________________________________
Medical Insurance Company _________________ Policy Number ______________________
Recent Health Issues: ______________________ ___________________________________
_________________________________________ ___________________________________
Please fill out, sign and return with your application. Send to:
CBCC Youth Initiative
2851 S. Parker Road, Ste. 560, Aurora, CO 80014
OR Fax to (303) 755-7363
Camp $tartup 2014
Waiver of Liability and Release Agreement
MEDIA RELEASE FORM
I, the undersigned, do hereby consent and agree that the CBCC Youth Initiative, Camp $tartup, its
employees, or agents have the right to take photographs, videotape, or digital recordings of my child and
me during the camp and to use these in any and all media, now or hereafter known, and exclusively for
the purpose of marketing the camp and the organization’s activities. I further consent that my child’s
name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to the CBCC Youth Initiative, Camp $tartup, its agents, and employees all rights to
exhibit this work in print and electronic form publicly or privately and to market and sell copies. I waive
any rights, claims, or interest I may have to control the use of my and the child’s identity or likeness in
whatever media used.
I understand that there will be no financial or other remuneration for the recording, either for initial or
subsequent transmission or playback.
I also understand that the CBCC Youth Initiative and its Camp $tartup is not responsible for any expense
or liability incurred as a result of my child’s participation in this recording, including medical expenses
due to any sickness or injury incurred as a result.
I represent that I am at least 18 years of age and the parent/guardian of a child participating in the Camp
$tartup program. I have read and understand the foregoing statement, and am competent to execute this
agreement.
Student’s Name
Parent’s Name
Street Address
City
ZIP
Phone Number
Parent’s Signature
Date