CWA SPONSORED FUNCTION

Transcription

1 CWA SPONSORED FUNCTION REGISTRATION AND PERMISSION FORM AND RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT.... REGISTRATION PLEASE PRINT AND COMPLETE EACH ITEM IN FULL Registrant s Name: (separate form for each Registrant.) Sex: Male Female Age: Birth Date: Address: City: State: Zip: Has Registrant previously attended CWA Function? Yes No Parent/Legal Guardian: Address (if different from Registrant s): Telephone: Home: ( ) - Work: ( ) - Mobile: ( ) - Other: ( ) Certain individuals are restricted or prohibited from possessing firearms, ammunition, and/or dangerous weapons because of a court order, a prior conviction, or immigration status. Can you legally possess a firearm and ammunition? [ ] Yes [ ] No... PERMISSION TO PARTICIPATE IN CAMP ACTIVITIES, AND RELEASE AND WAIVER OF LIABLITY AND INDEMNITY AGREEMENT The, sponsored by the California Waterfowl Association (CWA), is set in a natural environment. The Registrants participate in sporting clays, water activities, archery, and other outdoor or sporting activities, as described in the CWA event flyer. The Undersigned parent/guardian hereby requests that the above-named Registrant be permitted to attend the CWA Function. In consideration for the Registrant being permitted to attend the event and to participate in the activities described in the CWA event flyer, other than those activities, if any, designated in paragraph 5, below, the Undersigned, for him/herself, his/her personal representative, assigns, heirs, relatives or next of kin, the Registrant, and any other parent or guardian, acknowledges, agrees, and represents the following: 1. The Undersigned acknowledges and understands that the Registrant will be exposed to certain risks of injury presented by the natural environment in which the camp is located. 2. The Undersigned further acknowledges and understands that the Registrant risks being injured if he/she participates in such activities as sporting clays, water activities, archery, and similar outdoor and sporting activities, as described in the CWA event flyer. 3. The Undersigned expressly agrees that, in consideration for the privilege of attending this event, the Registrant shall use all services and facilities at the Registrant s sole risk. 4. The Undersigned affirms that he/she has read the CWA Function event flyer and is familiar with the activities that are offered to the Registrant while he/she is at the camp. 5. The Undersigned specifies that the Registrant may participate in any of the activities listed in the CWA event flyer and offered while he/she is attending the camp.

2 6. Although CWA does not expect any changes in the event schedule or activities, the Undersigned agrees that, due to unforeseen circumstances, changes may occur and that CWA is not obligated to give the Undersigned prior notification of such changes. 7. If any emergency medical procedures or treatment are required by the Registrant during his/her attendance at the camp or participation in camp activities and services, the Undersigned consents to the camp staff taking Registrant for emergency care and arranging for and consenting to the procedures or treatment recommended by the treating physician, pursuant to the Registrant Health Form included in the registration materials and agreed to as a condition of Registrant s attendance at the camp. The Undersigned hereby agrees to pay for the costs of any such medical procedures or treatment. 8. The Undersigned knowingly, voluntarily, and for adequate consideration releases and waives, and further agrees to indemnify, hold harmless, and reimburse CWA, members of its Board of Directors, and its employees and volunteers from and against any claim which the Registrant, the Undersigned, any other parent or guardian, relative or next of kin of the Registrant, or any other person, firm, or corporation may, now or hereafter have or claim to have, known or unknown, seen or unforeseen, directly or indirectly, or within or without the control of those released, for or on account of any losses, damages, personal injuries, pain and suffering, death, property damage, or contract claims resulting from, or arising out of, during, or in connection with the Registrant s attendance at the CWA Function and participation in the activities described in the CWA event flyer, and the rendering of emergency medical procedures or treatment, if any. 9. The Undersigned hereby agrees not to sue or file a claim against CWA, members of its Board of Directors, or its employees or volunteers for any death or injury to the Registrant or the Registrant s personal property sustained in connection with the Registrant s attendance at camp and participation in the activities described in the CWA event flyer, and the rendering of emergency medical procedures or treatment, if any. 10. The Undersigned expressly agrees that this Release and Waiver of Liability and Indemnification Agreement is attended to be as broad and inclusive as is permitted by California law and, if any portion of this Agreement is held invalid, it is further agreed that the remaining portions shall continue in full force and effect. 11. By signing this Waiver, the Undersigned acknowledges that he/she has carefully read, fully understands the contents of, and has voluntarily signed this Release and Waiver of Liability and Indemnification Agreement and further agrees that no oral representations, statements, or inducements apart from this Agreement have been made. 12. Certain individuals are restricted or prohibited from possessing firearms, ammunition, and/or dangerous weapons because of a court order, a prior conviction, or immigration status. Please mark an X in the appropriate box below and sign this form. I certify that I am a United States Citizen or lawfully within the United States, and that I am not restricted or prohibited due to court order, terms of probation, terms of parole, immigration status, or violations of certain sections of law from possessing firearms, ammunition, and/or dangerous weapons. I certify that I am restricted or prohibited due to court order, terms of probation, terms of parole, immigration status, or violations of certain sections of law from possessing firearms, ammunition, and/or dangerous weapons, and I understand that I cannot handle firearms while attending a Hunter Education class. If you are restricted or prohibited, speak with the instructor immediately. By signing below, I declare under penalty of perjury that the foregoing is true and correct. Date:, 20 Signature of Parent or Legal Guardian (Registrant is under 18 years of age) Date:, 20 Signature of Registrant

3 CWA WEEKEND WATERFOWL CAMP CAMPER HEALTH FORM To be completed by Parent or Guardian Camper s Name: Age: Sex: Male Female Camp Dates: Complete and correct health information and a parent/legal guardian s proper signature are REQUIRED before Camper will be permitted to attend camp. CAMPER S HEALTH HISTORY Check any condition the Camper has that a camp counselor should know about: Heart Condition Bed-Wetting Rheumatic Fever Diabetes Eye/Ear Infection Sleep-Walking Allergy/Bee Sting Convulsions Homesickness Drug Allergy Poison Oak Contact Lenses Headaches Nosebleeds HIV Food Allergies Other Please explain any items marked above: Is Camper taking any medication? Yes No / Name(s) of any medication: Does Camper have any physical impairment which requires accommodation? Yes No Explain: Other health information the camp counselors should know about: IMPORTANT: Please notify the camp if camper has been exposed to any communicable diseases within three weeks prior to reporting to the camp. Page 1 of 2

4 Camper Health Form (continued) IMMUNIZATION HISTORY D.P.T. Series Booster Polio Booster Measles Booster Other Booster Date of most recent Tetanus Immunization IN CASE OF EMERGENCY, I,, as the parent or legal guardian of, understand that first aid will be available at camp, that the Camper will be closely supervised, and that, if serious injury or illness develops, medical and/or hospital care will be given. I further understand that I will be notified in case of serious injury or illness. However, if it is impossible to contact me, I give my permission to the physician selected by the camp staff to hospitalize, to secure proper treatment for, and to order prescriptions, anesthesia, or surgery for my child named above. Medical Insurance: Family Physician: Subscribers Name: Phone (Office): Member or Group Number: Date:, 20 Signature of Parent/Legal Guardian Printed Name of Parent/Legal Guardian Emergency Contact Telephone Numbers: Name: Relation: Home: Work: Mobile: Other: Additional Comments: Page 2 of 2

5 CAmp CWA Weekend Waterfowl Camp Code of Conduct Camper s Name: Camp Dates: During my stay at the CWA Weekend Waterfowl Camp: I promise to conduct myself in a responsible manner, treating everyone with courtesy and respect. I will consider myself an invited guest of Rancho Esquon and conduct myself in such a way that I may be welcome to return in the future. I will obey the rules of the camp and the direction and instructions of the camp staff, and I will insist that others with me do the same. I will not participate in any verbal or physical abuse toward any other camper or adult. I will treat all animals and property with respect. I understand that if I violate any of the above I will be required to immediately call my parents to explain what happened and what I did wrong. This call will also inform my parents that the next violation will result in a call home to immediately come to pick me up and take me home. Date:, 20 Signature of Camper Date:, 20 Signature of Parent/Legal Guardian

6 CWA WEEKEND WATERFOWL CAMP PERMIT FOR CAMPER PHOTOGRAPHIC AND VIDEOTAPE REPRODUCTION Camper s Name: Camp Dates: The Undersigned parent/legal guardian of the Camper named above hereby gives permission to California Waterfowl Association (CWA) to photograph, film, or videotape the Camper during the time the Camper is attending a CWA camp and participating in any activities and services at or sponsored by the camp. 1. The Undersigned understands and acknowledges that these photographs and/or electronic reproductions may be used for promotional and/or public information purposes, including, but not limited to, CWA newsletters and web sites. The Undersigned further understands and acknowledges that the Camper s name may be included along with the photograph and/or electronic reproduction. 2. The Undersigned unconditionally releases and discharges CWA, members of its Board of Directors, and its employees and volunteers from all claims, rights, and causes of action arising out of or in connection with the use or publication of these photographs and/or electronic reproductions, including, without limitation, any and all claims for invasion of privacy and libel. This release shall inure to the benefit of the assigns, licensees, and personal representatives of CWA, members of its Board of Directors, and its employees and volunteers, as well as to the parties for whom the pictures were taken. 3. The Undersigned agrees that such photographs and electronic reproductions may be used, revised, or reproduced for distribution to other nonprofit organizations that organize and/or promote children s sports activities or the news media for promotional, educational, or informational use. Date:, 20 Signature of Parent or Legal Guardian (Camper is under 18 years of age.) Printed Name of Parent or Legal Guardian