read more - Harmony School of Excellence

Camp Area: 325 Mission Valley Road, New Braunfels, TX 78132
830.625.9105 | 800.444.6204
SUMMER LEADERSHIP CAMP
https://www.newktennis.com/outback-team-building.php
Applications to Bunyamin Murat
College Readiness & Leadership Program Coordinator
GENERAL OVERVIEW
Location and Dates. The Program site is the comfortable, supportive and wellsupervised camp and education facilities of the John Newcombe Tennis Ranch
Tennis Academy. The Program is offered from Sunday 5:00 pm until Friday 10 am
_May 31st through June 5th.
Camp Fee: $300
The cost will include 5 nights lodging, 14 meals beginning with dinner on the 31st,
programmed activities, team building, low and high ropes, orienteering, campfire, tubing,
tennis course, and use of the facilities
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SUMMER LEADERSHIP CAMP RELEASE AND WAIVER OF LIABILITY AGREEMENT
This agreement is by and between Cosmos Foundation, Inc. d/b/a Harmony Public Schools (“Harmony”), a Texas Open-Enrollment Charter School,
and the undersigned Student and Parent or Legal Guardian, and concerns the Student’s participation in the HARMONY SUMMER
LEADERSHIP CAMP. For the purposes of this agreement, the HARMONY SUMMER LEADERSHIP CAMP includes any activities involving
use of the education facilities located at New Braunfels, including, but not limited to, educational instruction, group or individual study sessions,
recreational activities, free play, food or beverage consumption, and sleeping. In addition, the HARMONY SUMMER LEADERSHIP CAMP
may include activities conducted off the premises, as well as transportation to and from these activities.
Information
Student Name: ______________________________________________________ Student ID #: _______________________ Male: ☐ Female: ☐
School: _____________________________________________________ Class/Grade Level: ________ Dates of Participation: ________ - ________
Parent(s) or Legal Guardian(s): __________________________________________________________ Email: ______________________________
Address: ________________________________________________________________________________________________________________
Home Tel.: _______________________________ Work Tel.: ________________________________ Cell: __________________________________
Acknowledgement and Consent
The undersigned Student and Parent/Legal Guardian hereby gives permission for the Student to participate in the Harmony Study Dorm Program
and all related activities for the days indicated above. The undersigned has received and read all the information relating to the Harmony Study
Dorm Program and is aware of the guidelines and policies applicable to the Student, including the rules of student conduct, during participation
in the program.
The undersigned acknowledges the risks and dangers associated with participation in the Harmony Study Dorm Program, which could result in
property damage or bodily injury, including death or permanent injury, and may be caused by the action, inaction, or negligence on the part of
Harmony, its Board of Directors, officers, servants, agents, or employees. Further, the undersigned acknowledges and accepts that there may be
risks not known or not reasonably foreseeable at this time. THE UNDERSIGNED UNDERSTANDS AND ASSUMES ALL RISKS INHERENT TO THE
HARMONY STUDY DORM PROGRAM AND RELATED ACTIVITIES, WHETHER KNOWN OR UNKNOWN, AND THAT BY SIGNING THIS DOCUMENT, IS
GIVING UP ITS RIGHT TO SUE.
Release and Waiver of Liability
In consideration for permitting the Student to participate in the Harmony Study Dorm Program, the undersigned Student or Parent/Legal
Guardian, on behalf of himself/herself, the minor Student, and his/her respective family members, spouses, heirs, assigns, and personal
representatives, voluntarily RELEASES, WAIVES, DISCHARGES, and PROMISES NOT TO SUE Harmony Public Schools, its Board of Directors, or any
of its officers, servants, agents, or employees (the “Releasees”) from any and all liability, claims, demands, and causes of action whatsoever arising
out of or related to any loss, damage, or injury, including death, sustained by the Student, or to any property belonging to the Student, whether
caused by the negligence of the Releasees, or otherwise, while participating in the Harmony Study Dorm Program, or while in, on or upon the
premises where the Harmony Study Dorm Program is being conducted, or in transportation to and from said premises.
All parties agree that this Release and Waiver of Liability shall be construed in accordance with the laws of the State of Texas, and that if any
portion of this agreement is held invalid, the other provisions shall continue in full force and effect. This Release and Waiver of Liability shall be
a bar to nay recovery by the Student and/or the Parent(s) or Legal Guardian(s) in any action instituted by any of them to recover for loss suffered
as a result of participating in the Harmony Study Dorm Program.
Signature of Student and Parent/Legal Guardian for Students Who Are Minors:
I certify that I am the custodial parent or am the Legal Guardian of the Student. I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND AND
AGREE TO ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY AND AN ASSUMPTION OF RISK.
Student’s Signature: ____________________________________________________________________ Date: _____________________________
Parent or Legal Guardian’s Signature: ______________________________________________________ Date: _____________________________
2
SUMMER LEADERSHIP CAMP CONSENT TO MEDICAL TREATMENT/RELEASE
Student Name: _____________________________________________________
Date of Birth: _______________________
Age: ___________
As the natural parent and/or the legally authorized guardian of the aforementioned minor, I grant my authorization and
consent for the respective officers, directors, volunteers and employees of Cosmos Foundation, Inc. d/b/a Harmony Public
Schools and the HARMONY SUMMER LEADERSHIP CAMP, to administer general first aid treatment for any minor
injuries or illnesses experienced by the Student. If the injury or illness is life threatening or in need of emergency treatment, I
authorize the Supervising Adult to summon any and all professional emergency personnel to attend, transport, and treat the
participant and to issue consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis,
treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician,
surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in which such
treatment is to occur.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority
and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such medical
or emergency personnel.
This authorization is effective commencing on the _____day of ____________________, 2015 and expiring on the ______day
of ___________________, 2015.
I agree to authorize release of any medical information to process insurance claims and request payment of benefits to the
physicians or supplier for services described, and to provide any other consent(s) required by federal and state law to
effectuate such release. I understand that should the insurance not cover this illness/injury, I will be responsible for payment
in full of any charges incurred.
MEDICAL HISTORY
Does the Student have a known history of: (Circle Y/N)
A. Birth Deformities (one eye, kidney, etc.)
B. Medical conditions currently under treatment
C. Preexisting injuries currently under treatment
D. Fractures or other disability type injuries
E. Allergy (drugs, food, asthma, etc.)
F. Mental disorder or convulsions
G. Known past illness of more than one week
H. Contact lens or glasses
YES
YES
YES
YES
YES
YES
NO
YES
YES
NO
NO
NO
NO
NO
NO
NO
Explain above questions answered “yes”
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I hereby state that Cosmos Foundation, Inc. d/b/a Harmony Public Schools and the Harmony Summer Ledaership Program are
not responsible, individually or collectively, for any preexisting injury or illness of the above participant.
Parent or Legal Guardian Signature (Required)
Parent or Legal Guardian Name (Please Print)
3
Participant Medical History & Liability Release Form - Newcombe Ranch
Name _________________________ Phone ___________________ Date of Birth ____________
Address _________________________________________________________________________
Male ( ) Female ( ) Height_______ Weight_______
In case of emergency, please notify______________________________ Phone _______________
Do you have any medical or health conditions which you believe could affect your capacity
to participate in this program? Yes____ No_____ If "Yes", please explain on the back of this form.
List any medications to which you are allergic ___________________________________________
Please check Yes or No for the following as they apply to you:
I have:
Yes
No
Description:
a physical disability
___
___
___________________________________
had surgery in the last 6 months
___
___
___________________________________
heart or circulatory problem
___
___
___________________________________
problem with seizures
___
___
___________________________________
sight, hearing or speech impairment
___
___
___________________________________
asthma or respiratory problem
___
___
___________________________________
arthritis or problems with joints
___
___
___________________________________
allergies, diabetes or hypoglycemia
___
___
___________________________________
headaches, dizziness, heatstroke
___
___
___________________________________
reactions to bee stings or insects
___
___
___________________________________
high blood pressure
___
___
___________________________________
other:
___
___
___________________________________
Are you pregnant?_______ How many months?__________
I understand that all participation in this program is by choice and that I may exercise the option to not participate in
any aspect of this program (physical, cognitive, or emotional) if in my judgement I determine that I may be at risk or
unable to participate for any reason. In the event of an accident or emergency that renders me unable to
communicate (or as the parent of a minor who cannot be contacted), I grant my permission for any medical
care, operations, and charges which might become necessary.
Release of Liability – Read before Signing
As with any program associated with the outdoors, there is a risk which must be assumed by each participant in the
event that he/she may experience any emotional or physical injury. Knowing the inherent risk and rigors involved in
the activities, I certify that I am fully capable of participating in the activities. I voluntarily assume and accept full
responsibility for my behavior, and for all risk of injury, illness, death, loss of personal property, and expenses thereof,
as a result of my negligence, or other risks, including but not limited to those caused by physical obstacles, the
terrain, the weather, my emotional and physical condition, and other participants. I agree to release, discharge and
agree to indemnify and hold harmless, The John Newcombe Tennis Ranch, their agents, assistants, employees and
any co-sponsors (when applicable) for any damages or injuries, physical or mental which might occur as a result of
my voluntary decision to participate in these activities.
I have read this release of liability and assumption of risk agreement, fully understand its terms,
and sign it freely and voluntarily without any inducement.
Participant's Signature ________________________________ Age _________ Date __________
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her
release as provided above of all the Releasees, and, for myself, my child, and our heirs, assigns, and next of kin, I
release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor
child’s involvement or participation in these programs as provided above.
Signature of Parent or Guardian (if under 18) ________________________________ Date ________
Insurance: _____________________________ Subscriber # _______________________ Group # ______________
( If there is no insurance coverage, that section can be left blank )
Directions to The John Newcombe Tennis Ranch
325 Mission Valley Road
New Braunfels, Texas 78132
From Austin / Dallas
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Hwy 35 South to New Braunfels (Approximately 45 miles south of Austin)
Exit #189
(Seguin/New Braunfels)
Turn right at stop light - you will then be going west on Loop 337
Go 5 miles on Loop 337 until you come to the Hwy 46 exit - Take that exit and turn right at stop light
Go about 2 miles on Hwy 46 and you will see a big water tower on your left that says "Newks Resort"
Turn left at the tower (Mission Valley Road) and stay on that road about 1/2 mile
The main entrance will be the 2nd set of buildings on the left. The Main Lodge is by the parking lot.
From Houston
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Hwy 10 West to Seguin
Take the New Braunfels exit and go west on Hwy 46. Stay on it about 15 miles to New Braunfels
When you go under Hwy 35 in New Braunfels, Hwy 46 turns into Loop 337 (McDonalds on right!)
Follow Loop 337 west about 5 miles until you come to the Hwy 46 exit - Take that exit and turn right at
stop light
Go about 2 miles on Hwy 46 and you will see a big water tower on your left that says "Newks Resort"
Turn left at the tower (Mission Valley Road) and stay on that road about 1/4 mile
The main entrance will be the 2nd set of buildings on the left. The Main Lodge is by the parking lot.
From San Antonio
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Hwy 35 North to New Braunfels
Take the Rueckle Road exit - Turn left at stop sign and pass over Hwy 35
You will be on Loop 337 going west - Go about 3 miles until you come to the Hwy 46 exit
Turn left at the stop light and go west about 2 miles on Hwy 46
You will see a big water tower on your left that says "Newks Resort"
Turn left at the tower (Mission Valley Road) and stay on that road about 1/4 mile
The main entrance will be the 2nd set of buildings on the left. The Main Lodge is by the parking lot.
From Boerne / West Texas
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Hwy 10 East to Hwy 46 exit (in Boerne)
Go east on Hwy 46 towards New Braunfels
We are 15 miles east of Hwy 281
You will see a big water tower on your right that says "Newks Resort"
Turn right at the tower (Mission Valley Road) and stay on that road about 1/4 mile
The main entrance will be the 2nd set of buildings on the left. The Main Lodge is by the parking lot.
If you have any questions, please call us at (830) 625-9105
What to Bring to Newk's!
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Comfortable clothing & shoes (depending on the weather)
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Swimsuit & towel (seasonal)
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Flashlight (not essential - you don't need to buy one - bring one if you have it!)
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Toiletry items (towels, toothbrush, toothpaste, soap, shampoo, etc.)
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Bedding (sleeping bag or sheets & blanket)
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Pillow
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Camera / Video Camera
(optional – great memories!!)
If you need to contact someone while they are at The John Newcombe Tennis Ranch,
please call (830) 625-9105. Between 9:00pm and 8:00am please call (210) 857-9370.