University of California, Irvine



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ANTEATER RECREATION SUMMER CAMP

COMPLETING YOUR WAIVER FORMS

All forms must be printed out, completed and sent to the Anteater Recreation Center at UC Irvine, at least 1 week (7 days) prior to the start of camp.

Camp Date: Waiver Forms Due:

June 19, 2017 June 12, 2017

June 26, 2017 June 19, 2017

July 5, 6, or 7 June 26, 2017

July 10, 2017 July 3, 2017

July 17, 2017 July 10, 2017

July 24, 2017 July 17, 2017

July 31, 2017 July 24, 2017

August 7, 2017 July 31, 2017

Forms may be delivered in the following ways:

In Person:

-Please put forms in an envelope/packet with ATTN: Anteater Recreation Summer Camps on the front.

-Forms can be accepted by Service Desk (located upstairs from the ARC Front Desk) personnel, Monday-Friday from 8am-6pm. Forms delivered outside of this time can be dropped off at the Front Desk. Please make sure the attendant knows it is for ARC Summer Camps.

By Mail to:

Campus Recreation Services

680 California Ave

Irvine, CA 92697

By Fax:

Please include a cover page with “Attn: ARC Summer Camps”

(949) 824-4822

By Email:

Forms may be scanned and emailed to camprec@uci.edu

Receiving your forms:

Once your forms have been received, you will be notified by email that your registration is complete. Registration is not considered complete until all forms have been completed and received (with confirmation email) by the Anteater Recreation Center.

If you do not receive a confirmation email within 2 business days of sending in your forms, please contact Kim Anderson at k.anderson@uci.edu.

Forms not received 2 weeks (14 days) prior to the start of camp will be notified by email that the deadline to turn in forms is in 1 week (7 days).

If forms are not received 1 week (7 days) prior to the start of camp, your child may be dropped from the camp.

Thank you,

Anteater Recreation Summer Camps

University of California, Irvine

Campus Recreation

Consent to Photograph

I authorize the University of California, Irvine (UC Irvine) to capture the name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements, or to permit others to do so, of ___________________________________________________ (Name of Individual) for use by UCI Campus Recreation and the Anteater Recreation Center in printed or electronic marketing and promotional materials, including the UCI Campus Recreation website and social media.

I waive and release the University of California and its officers, agents and employees, from any claim or liability relating to the use of my name, likeness, identity, voice, photographic image, videographic image and oral or recorded statements.

I acknowledge that the University of California will rely on this consent and release in producing, broadcasting, and distributing materials containing my name, likeness, identity, voice, photographic image, videographic image or oral or recorded statements, and that I will receive no money or remuneration of any kind from the University of California related to this consent and release or the materials covered by this consent and release.

I am an adult, 18 years or older, and I have read and understand this agreement and I freely and knowingly give my consent to the University of California as described herein.

______________________________________________

Signature of Individual (or of parent or guardian if individual is a minor)

______________________________________________

Relationship (if other than individual)

______________________________________________

Date

*Authorization required for camp group photo

|[pic] |UC Irvine – Campus Recreation |

| | |

| |Youth Programs |

| |Medical Consent Form |

I (we), the undersigned parent(s), or legal guardian of (Name of Child) ________________________, do hereby request that he/she be permitted to attend the UC Irvine Campus Recreation Youth Programs and should the need arise, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis and treatment rendered under the supervision of a licensed physician. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power to render care which the licensed physician in the exercise of his/her best judgment may deem advisable.

It is understood that, if possible, effort shall be made to contact the undersigned prior to rendering treatment but that any of the above treatments will not be withheld if the undersigned cannot be reached in a timely manner. I (we) will not hold liable the Regents of the University of California, its officers, employees, or agents for medical aid or first aid rendered and will be solely responsible for all medical or other expenses incurred in the care of my child.

I authorize release of information on this form to any licensed physician, hospital or medical staff member involved in the treatment or care of my child.

Parent/Guardian Name (Print): ______________________________________________

Parent/Guardian Signature: _________________________________________________

Medical Information:

Emergency Contact _____________________________________________ Phone _____________________

Current Medications ________________________________________________________________________

Pertinent Medical History ____________________________________________________________________

Allergies _________________________________________________________________________________

Insurance Information (Required)

Insurance Company ________________________________________________

Policy Holder Name ________________________________________________

Policy Number ____________________________________________________

Parent/Guardian Release

I am the parent or legal guardian of ___________________________ and I have read and understood and agree to the terms and conditions of this application and I am signing this release on behalf of said minor.

Parent/Guardian Signature: ___________________________________________ Date: _________________

Participant’s Name:______________________________

Please Print

UNIVERSITY OF CALIFORNIA, IRVINE

Campus Recreation and Anteater Recreation Center Youth Camp

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in

Campus Recreation or Anteater Recreation Center Youth Camp Programs. Including but not limited to participating in Archery, Badminton, Cooking, Fencing, Floor Hockey, High Ropes, Rock Climbing, Lacrosse, Athlete Performance, Yoga&Swim and Other Youth Programs or other Drop-in Activities, hereinafter called “The Activity”, I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue The Regents of the University of California, its officers, employees, and agents from liability from any and all claims including the negligence of The Regents of the University of California, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.

_________________________________ __________________________________

Signature of Parent/Guardian of Minor Date Signature of Participant Date

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

___________________________________ ____________________________________

Signature of Parent/Guardian of Minor Date Signature of Participant Date

Participants Age (if minor) ________

Volwaiver 12/14

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|Camp Code of Conduct |

|Camper Agreement |

|The Anteater Recreation Summer Camp Staff will enforce these rules during camp to ensure the well-being, safety and enjoyment of each camper! Please |

|go over these rules with your camper so they are aware before the start of camps. |

|1. |Campers are not allowed to leave the Camp area for any reason without being escorted by a Camp Assistant. |

|2. |All restroom and water break trips will be taken with at least 2 campers and 1 assistant. Assistants are not allowed in restrooms while |

| |occupied by campers. |

|3. |Always listen to the Head Coach/Instructors rules during camp. They are in place for your safety and enjoyment of camp! |

|4. |We have a zero-tolerance bullying policy. No name calling or inappropriate language will be allowed. No inappropriate physical contact is |

| |permitted. No hitting, kicking, spitting, etc. |

|5. |Possession of any type of weapon will not be permitted. Weapons include knives, guns, pellet guns, BB guns, sling shots, water pistols, or any|

| |other kind of device that could inflict injuries to yourself or others. |

|6. |Do not use equipment for anything other than its intended purpose during camp. Equipment may not be used to hit or touch another camper. |

| |Equipment must be shared by all campers. |

|7. |Participants who abuse or damage University property will be billed for the cost of the damage. |

|8. |Tell a camp staff member if there is any problem/issue during camp that is making you unhappy. |

|9. |Use the “Golden Rule”! Treat other campers and camp staff how you would want to be treated! |

I, , understand that any violation to this code of

(Please print camper name)

conduct may result in expulsion from the ARC Summer Camp program.

Participant’s Signature: _________________________________________ Date: __________________

Parent/Guardian Signature: _________________________________________ Date: _______________

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CAMPER PICK UP AUTHORIZATION (Please list those authorized other than Parent/Guardian listed above)

Parent/Guardian Authorization Signature_____________________________________________________________________________________________

1._________________________________________________________________________________ Phone_______________________________

2._________________________________________________________________________________ Phone_______________________________

CAMPER RELEASE AUTHORIZATION (CHILDREN 12 AND OVER)

I Request UC Irvine Campus Recreation to allow my child to release him/herself at the end of camp.

Parent/Guardian Authorization Signature____________________________________________________________________________________________

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