Child’s Full Name: Date of Birth:
Mother’s Full Name:
Father’s Full Name:
Guardians Full Name:

Camper Waiver Packet

This packet is very important for the registration of each camper. The information we are asking for will help the Super Kids Camp staff offer the best and safest camp possible. All of the requested information must be completely filled out and returned prior to your camper attending Super Kids Camp.

Registration opens Wednesday, April 1st.

Return this waiver packet to the SSU Recreation Center or the SSU Student Center at the front desk. After your registration packet is received, you will be emailed a confirmation letter. Information in this packet details the day-to-day procedures of camp.

Payment Details

There is a one-time non-fundable registration fee of $40 per family. This fee is waived for currently enrolled SSU students, faculty, and staff.

Physical and online registration/ waiver forms need to be completed by the Wednesday prior to the session being attended. Campers will not be able to attend camp until the packet is completed and turned into the Sonoma State Recreation Center or Student Center.

A deposit can be made by the Wednesday prior to a session being attended to reserve your child’s space. Deposits are per camper at $5 a day or $25 for a full week.

Payments need to be made the Wednesday prior to the session being attended to avoid a $20 late fee.

There is a $35 refund fee for any transaction.

Camper Information Sheet

Camper’s Full Name: Date of Birth:
Do you expect your child will have any special concerns about swimming at SKC?
(Circle) Yes No
If yes, please describe possible problems and any suggestions you may have to help with the situation.
Will you be sending you child with a life jacket?
(Circle) Yes No
How would you rate your child’s general athletic ability for his/her age group?
(Circle) Above Average Average Fair
Does your child have any problems participating in large group activities?
(Circle) Yes No
If yes, do you have any suggestions on how we could help your child have a better time when participating in these activities?
Is there anything you would like your child to accomplish while at Super Kids Camp? (Please explain below)

Medical Information & Certification of Health

This is to certify that ______is in good health; has had a complete physical within the last year; has to had no recent exposure to a contagious disease and has had no operation or serious illness since his/her last health examination. *If camper has had serious illness or an operation since last examination, written permission must be obtained from a physician for the child to attend Super Kids Camp.
Date of Last Examination:
Polio Immunization? (Circle) Yes No / Tetanus Shot Date:
Please list any allergies, disabilities, or conditions that should be known to the staff:
Has your child been taking any medications in the past 6 months that they will not be taking at camp? (Circle) Yes No
If yes, please briefly explain:
Is your child currently taking any medications? / Yes / No
Will your child need medications administered at camp? / Yes / No
*Medications will be administered by the Camp Director as specified by parent and/or physician
Briefly describe the condition for which your child is taking medication:
Family Physician: / Phone:
Medical Insurance Company:
Policy#: / Exp:
Emergency Contact Number:

Medical Information & Certification of Health

I understand that I am required to have accidental medical coverage for the child listed on this application and I verify that the information provided on my insurance policy is accurate and true.
In case of emergency and I cannot be reached, I authorize the staff of the Recreation Center to obtain whatever medical treatment he/she deems necessary for the welfare of my child listed on this application. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether my medical insurance would cover such charges and fees.
Signature of Parent or Guardian: ______Date: ______
Each parent or guardian, whose child participates in any phase of Super Kids Camp, assumes responsibility for his or hers child’s health and physical well-being. Participation in Super Kids Camp is on a voluntary basis. Therefore, neither the Sonoma State University, Sonoma Student Union Corporation, nor the Campus Recreation department will accept responsibility for ill health or injury sustained while participating in Super Kids Camp.
The staff of this department recommends that any person who participates in any phase of the Super Kids Camp program undergo a physical examination prior to participation.
I verify that ______is in good health and able to participate in Super Kids Camp.
Signature of Parent or Guardian______Date: ______
Name: Date of Birth:
Address:
City/State/Zip:
Emergency Contact: Phone #:
Release of Liability/Agreement Not to Sue for Climbing Wall Activities
I, ______, am aware that rock climbing/artificial wall climbing and bouldering include certain risks including but not limited to the risk of injury or death. I am voluntarily and participating in this activity and/or instruction about this activity with knowledge of the dangers involved, and hereby agree to accept full responsibility for the risks and dangers involved.
  1. I agree that I will not sue, or otherwise make any claim against Sonoma State University, Sonoma Student Union, or their EMPLOYESS, agents (whether paid or volunteer), and contractors, for any loss, injuries, or damages resulting from participation in rock climbing/artificial wall climbing and/or bouldering at Sonoma State University’s Campus Recreation Climbing Wall.
  2. I agree Sonoma State University’s Campus Recreation Climbing Wall, its employees, agents, and contractors, will not legally be responsible for any loss, injury or damage of any kind to me, my heirs, or assigns, resulting from any cause, including negligence.
  3. I agree to use the climbing facilities according to the rules and regulation of Sonoma State University’s Campus Recreation Climbing Wall.
  4. I agree that as to any equipment, which I provide or borrow or rent from Sonoma State University’s Campus Recreation Climbing Wall during any climbing/or other indoor our outdoor activity, I use at my own risk. I understand and agree that Sonoma State University’s Campus Recreation Climbing Wall shall not be liable for any loss, damage, or injury resulting from the use of said equipment. Sonoma State University’s Campus Recreation Climbing Wall makes no warranties regarding said equipment.
  5. To the fullest extent allowed by law I agree to RELEASE, INDEMNIFY and HOLD HARMLESS Sonoma State University’s Campus Recreation Climbing Wall, its employees agents, and contracts from all actions or claims which could be brought by myself, my heirs, assigns or personal REPRESENTIVE(s) for any loss, injury or damaged sustained during and resulting from participation in rock climbing/artificial wall climbing and/or bouldering at Sonoma State University’s Campus Recreation Climbing Wall including any loss, injury or damage resulting from use of equipment.
  6. The terms of this release shall also be binding as to any other persons, including family MEMBERS, heirs, executors or administrators, and including any minors who may accompany me. I understand that this is a binding contract which supersedes any other agreements or representations, and is not intended to provide a comprehensive and complete release of liability, but is not intended to assert defenses which are prohibited by law.
  7. I am legally competent to sign the release; or, my parent or guardian has read and signed this release. I have carefully read this agreement. I fully understand its contents and sign it on my own free will.

Participant Signature: Date:
Must also be signed by parent or legal guardian if Participant is a minor, under 18 years of age.
Participant Guardian Signature: Date:
If I am signing on behalf of a minor, in addition to the terms above, I also agree to Release, Hold Harmless and Indemnify Sonoma State University’s Campus Recreation Climbing Wall, and its employees, agents, and contractors for any claim the minor could bring. I agree to be solely responsible for any medical or legal expenses incurred by the minor.
Accepted by Sonoma State University’s Campus Recreation Climbing Wall Staff Signature:

Campus Recreation Climbing Wall Waiver

Release of Liability – Promise Not to Sue – Assumption of Risk

Agreement to Pay Claims – Permission to use Visual Likeness

Page 1 of 2

Activities:

  1. USE OF SSU RECREATION CENTER FACILITIES, EQUIPMENT, PROGRAMS, CLASSES, EVENTS AND SERVICES.
  2. USE OF SSU POOL FOR CAMPUS RECREATION PROGRAMS.

Effective Locations and Time Periods:

  1. RECREATION CENTER: DURING HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND INCLUDING August 31, 2015.
  2. SSU POOL: DURING CAMPUS REC SWIM HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND INCLUDING August 31, 2015 AS WELL AS DURING ANY OTHER TIMES DURING THIS PERIOD IN WHICH CAMPUS RECREATION SPONSORS PROGRAMS/ ACTIVITIES IN THE POOL.

In consideration for being allowed to enter and use the Recreation Center and equipment, and participate in its activities, including use of the SSU Pool, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California, the Trustees of the California State University, California State University, Sonoma State University, and its employees, officers, directors, volunteers and agents (collectively “University”) and the Sonoma Student Union Corporation and its employees, officers, directors, volunteers and agents (collectively “Auxiliary Organization”) from any and all claims, including claims of the University’s or Auxiliary Organization’s negligence resulting in any physical or psychological injury (including paralysis and death), illness, property damage or economic or emotional loss I may suffer because of my presence and/or participation.

I am voluntarily entering and using the Recreation Center and SSU Pool. I am aware of the associated risks which include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, death and/ or property damage. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction, negligence, conditions related to the condition of the Recreation Center and SSU Pool. Nonetheless, I assume all related risks, both known or unknown to me, of my presence and participation.

I agree to hold the University and Auxiliary Organization harmless form any and all claims, including attorney’s fees and/ or damage to my personal property that may occur as a result of my presence and/or participation in Recreation Center and SSU Pool facilities, equipment, programs, classes, events, and services. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I grant permission for Campus Recreation staff to take, and make public, visual/ audio images of me. I agree that Campus Recreation owns the images and all the rights to them. Without notifying me the images may be used in any manner or media including, but not limited to, University --- sponsored websites, publication, promotions, advertisements, and posters. I waive any right to inspect, approve, or be compensated for the use of such images.

As of the date below, I am 18 years or older. I understand the legal consequences of signing this document, including that I (a) release the University and the Auxiliary Organization from all liability, (b) promise not to sue the University and the Auxiliary Organization, and (c) assume all risks associated with my presence and participation in the Recreation Center and SSU Pool.

I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I sign it freely. No other representations concerning the legal effect of this document have been made to me.

Participant Signature: ______Date: ______

Participant Name (Print): ______Date: ______

NOTE: (If under 18 years of age as of the date above, a Parent or Guardian Signature is required on Page 2.)

Release of Liability – Promise Not to Sue – Assumption of Risk

Agreement to Pay Claims – Permission to use Visual Likeness

Page 2 of 2

This page is only required if participant is under 18 years of age.

If participation is under 18 years of age as of the date on Page 1, a Parent or Guardian Signature is required:

I am the parent or legal guardian of the person named on page 1. I understand the legal consequences of signing this document, including that I (a) release the University and the Auxiliary Organization from all liability on my and the Participant’s behalf, (b) promise not to sue on my and the Participant’s behalf, (c) assume all risks of the Participant’s presence and participation. I allow my dependent to be present and to participate. I understand that I am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by the terms of this document.

I have read this two---page document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me.

Signature of Minor Participant’s Parent/ Guardian: ______Date: ______

Name of Minor Participant’s Parent/ Guardian (Print): ______Date: ______

Minor Participant’s Name (Print): ______Date: ______

Date Minor Participant will turn 18 years old: ______

Minor Participant’s SSU ID# (if applicable): ______

Visual/Audio Image Release Form

I grant permission to Sonoma State University, its employees and agents, to take and use visual/audio images of me. Visual/Audio images are any type of recording, including photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. SSU will not materially alter the original images. The sponsored websites, publication, promotions, broadcasts, advertisements, posters, and theater slides, as well as for non-University uses. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them. I release SSU and its employees and agents, including any firm authorized to publish and/or distribute a finished product containing the images, from any claims, damages, or liability which I may ever have in connection with the taking of and/or use of the images or printed material used with the images. I am at least 18 years of age and competent to sign this release. I have read this release before signing. I understand its contents, and I freely accept the terms.
Printed name of subject:
Signature of subject:
Parent/guardian if under 18 years of age:
Telephone or email address:
Address (optional):
Date:
Year in School:
Project name: Super Kids Camp
Photographer’s name and contact information: Super Kids Camp (707) 584-4386

Please copy up to 6 ID’s on a blank page of paper, which will be added to the end of the packet. Please make sure all photos are legible. Staff will be checking ID’s at pick-up time. Children will only be able to leave with an adult that has a matching ID. If you have any questions about this please contact the Directors.

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