WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT This document affects your legal rights. You should read and understand it before signing it. In consideration for receiving permission to participate in Rec Sports Youth Camps (describe activity) on Summer 2010 , I hereby waive, release, and discharge any and all claims for (activity/trip date(s) damages for death, personal injury or property damage which I may have or which hereafter may accrue to me against the CSU, Chico Research Foundation, its programs, the State of California, the Trustees of the California State University, and the officers and employees, as a result of my participation in any way in the event described above. This release is intended to discharge The State of California, Trustees of The California State University, California State University, Chico, the CSU, Chico Research Foundation, officers, employees, students, and volunteers of each and any other public agency from and against any and all liability arising out of or connected in any way with my participation in the event/activity, even though that liability may arise out of the negligence or carelessness on the part of persons or agencies mentions above. I further understand that accidents and injuries can arise out of participation in this event/activity; knowing the risks, nevertheless, I hereby agree to assume those risks and to release and to hold harmless all of the persons or agencies mentioned above who (through negligence or carelessness) might otherwise be liable to me (or my heirs or assigns) for damages. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns. In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made. ______As parent/guardian, I certify that he/she is in excellent health and has no physical, mental or emotional problems which are likely to prevent participation in strenuous physical activity. I give permission for him/her to be medically treated for illness occurring or injury sustained during participation in the above activity, and certify that he/she is covered by medical insurance. I execute this Release for full, adequate and complete consideration fully intending to be bound by same. ____________________________________ _________________________________________ Name of participant (print) Signature of participant or guardian if under 18 ___________________________________________________________________________________________ Street Address City State Zip _______________________ Phone WITNESS: _______________________________ Printed Name of Witness ____________ Date ___________________________________ Signature of Witness CSU, CHICO RESEARCH FOUNDATION AUTHORIZATION TO TREAT A MINOR In the event that my son/daughter becomes ill or sustains an injury while in the care or under the supervision of the Rec Sports Youth Camps program (name of program), operated through the CSU, Chico Research Foundation, any of the adult supervisors of the activity is given my permission to administer first aid for his/her relief. If it is not practical to return him/her to me or to receive my instructions for his/her care: I, the undersigned parent or legal guardian of __________________________________________, a minor, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and emergency hospital care, which is deemed advisable by and is rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Health. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to provision of Section25.8 of the Civil Code of California. I further agree to not hold the above-named program or the CSU, Chico Research Foundation liable for the medical aid rendered and will make reimbursement for the medical or other expenses incurred for the care of the named minor. Parent/Legal Guardian Signature:_______________________________________Date:________________________ Relationship to Minor:____________________________________________________________________________ Medical Insurance Information: Name of Insurance Company:__________________________________________Policy #: _____________________ Name of Insured:____________________________________________________ Medical Information: Allergies to drugs or foods:______________________________________________________________________ Required medications & frequency:_______________________________________________________________ Date of last Tetanus Booster:____________________________________________________________________ Are there any activity limitations or special needs?:___________________________________________________ ____________________________________________________________________________________________ Any previous illness/injury that should be taken into consideration?______________________________________ Emergency Contact and Pick Up Information: Name:_________________________ Phone #:_____________________ Relationship:_______________________ In the event a parent/guardian cannot be reached, please indicate relatives or family friends who may be contacted in an emergency or for pick up. Alternates: Name:__________________________ Phone #:___________________ Relationship:______________________ Name:__________________________ Phone #:___________________ Relationship:______________________ Name:__________________________ Phone #:___________________ Relationship:______________________ CSU, Chico Research Foundation INFORMED CONSENT AGREEMENT This Agreement is to acknowledge that, in consideration of participation in the following program:____Rec Sports Youth Camps_________________________ (name of program/description of activity) to be held on:_______Summer 2010__________________________ (activity/trip date) I consent to the following: ! I understand that accidents and injuries can arise out of participation in activities such as this. Knowing this, I am willing to assume the risk that an accident or injury may occur, and agree to release the above parties from responsibility for risks associated with my participation in the program. ! I agree to release from liability and hold harmless the CSU, Chico Research Foundation, its programs, the Trustees of the California State University, and their officers and employees, from claims against them arising from injuries or property damage which might occur in connection with this activity. ! I certify that the participant is in good health and has the capacity to participate in programs of this nature. I ! I give permission for the participant to be medically treated for illness or injury occurring during participation in the above activity, and certify that he/she is covered by medical insurance. In the event that the participant is not covered by medical insurance, I agree and accept responsibility for costs associated with medical treatment. A completed “Authorization to Treat a Minor” form is attached.) _______________________________ _______________________________ Name of participant (please print) Signature of parent or guardian if under 18 ____________________________________________________ Street Address City State Zip ____________________ Phone Permission to Publish Photos On a Website or in Printed Materials Photos of activities taken during the __Rec Sports Youth Camps________ (name of camp) are important tools for publicizing and promoting future camps of this nature. Permission from a minor and parent/guardian is required to allow this to occur. To protect a child’s identity, names will not be published near or in reference to photographs. Only the camp director or administrator will have permission to add pictures to the publicity materials or website. Camp Participant Consent ! YES ! NO I give the CSU, Chico Research Foundation, CSU, Chico, and the CSU, Chico Recreational Sports Department permission to use by photograph for reproduction on either website or in printed materials for the sole purpose of publicizing the camp or for activities strictly related to the camp. I understand that my name will not be associated with the photograph. Date: __________________Camper Signature: _______________________________ Camper Printed Name: ___________________________ Parent/Guardian Consent I am the parent or the legal guardian of the above-named minor and hereby approve the use of her/his photograph pursuant to the terms described above. I affirm that I have the legal right to issue such consent. Date: __________________Parent/Guardian Signature: ________________________ Parent/Guardian Printed Name: _____________________ ASSOCIATED STUDENTS, INC FOREBAY AQUATIC CENTER STATEMENT OF RISKS, ASSUMPTION OF RISKS AND LIABILITY RELEASE Name of Outing: Rec Sports Youth Camps Date of Outing: Summer 2010 NAME: ________________________________________________ Phone # ___________________________________________ ADDRESS: ____________________________________________________________________________________________________ STREET CITY STATE ZIP Health & Accident Insurance Co. ________________________________Policy # ___________________________________________ Medical problems or allergic reactions: _____________________________________________________________________________ Medications currently taking: _____________________________________________________________________________________ Emergency Phone _______________________________________________________________________________________________ STATEMENT OF RISKS AND RESPONSIBILITIES: The material in this section is provided for your general information. Be sure to check the attachments to this form, if any, which describe specific risks and responsibilities associated with the particular activity in which you may be engaged. GENERAL RISKS: Please understand that when you participate in recreational activities in the indoors or outdoors, you are risking your physical being. It is impossible, however, to list all the dangers involved in any activity. The eventualities of injuries, death, or property damage are so diverse that no one can anticipate everything that can go wrong. Before you participate, you should become informed, as much as possible, about the inherent dangers associated with the particular activity in which you are to be engaged. Also, you should make sure that you are adequately prepared with the proper skills, equipment, and clothing to minimize these dangers. Here are only some of these possibilities: You can become ill or die from: polluted drinking water; improperly washed eating utensils; snake, insect, or animal bites; exposure to heat or cold; personal health complications, e.g., strokes, appendicitis, heart attack. You can also sustain injuries (sprained ankles, deep cuts, blisters, and other wounds) or die from: boating accidents; slipping off wet or mossy boulders or trees; being submerged in frigid water, colliding with a vehicle, boat, rock, log, or tree; being hit by lightening; hit by the boom of a sailboat; being bit by rattle snakes or other wildlife; falling and receiving injuries from sailing equipment, such as the mast, boom, rope (lines), and sail; becoming entrapped in a kayak, sailboat, pedal boat, hydro bike, or canoe; over exposure to the sun; receiving burns from hot fires, gas stoves, or other instruments; falling into the lake and drowning; flipping boats; as well as many other possibilities. Recognize that some outdoor activities take place far away from medical attention. Rescue, if possible, is often difficult and expensive. If you must be rescued, you will be expected to bear the costs of the rescue. Recognize also that injuries, death, and property damage may occur while rescue efforts are in progress. Therefore, please do not participate in this activity if you think it is perfectly safe. It is not! You and your fellow companions are expected to use common sense to reduce risk for yourself and to others. Personal Medical Conditions: It is your responsibility to check with a medical doctor to see if you have any medical or physical conditions which might create a risk to yourself or to others who would depend on you during this outing. These conditions may include, but are not limited to, the following: physical or medical disabilities; medication or drugs you may be taking; dietary restrictions; allergies or sensitivities to penicillin, insects, bees, poison oak, dust, foods, etc. You should discuss any potential problems with the activity leader prior to the outing. Use of Motor Vehicles and Insurance: Participating in this activity may involve the use of motor vehicles. If you drive or provide your own motor vehicle for transportation to or from the program site, you are responsible for your own acts and for the safety and security of your vehicle and those who ride with you. You must accept full responsibility for the liability of yourself and your passengers. You are not covered by insurance through California State University, Chico or the Associated Students. Associated Students does not insure personal property from damage or theft. Riding as a passenger: If you are a passenger in a private vehicle, you should understand that the California State University, Chico, the Associated Students, and Associated Students personnel, or volunteers are not in any way responsible for your safety during this outing. Further, recognize that Associated Students insurance does not cover any damage, theft, or injury suffered in the course of traveling in private vehicles. Obligation regarding own medical insurance: No personal medical insurance is provided. It is your responsibility to obtain proper personal medical and injury insurance. Participation in this activity is voluntary: Forebay Aquatic Centers’ activities are not required, nor is any specific activity within an outing required. If you feel a particular part of the outing is beyond your ability or if you feel it has some risks you are not prepared to accept, you should simply feel free not to participate in that aspect of the activity. It is your responsibility, however, to constantly evaluate outing activities and your ability to safely participate in such and make careful decisions whether or not you should participate. You participate at your own risk. Alcohol and drugs and are not permitted during any activity put on by the Forebay Aquatic Center. You are responsible: In order for this outing to be enjoyable, it means that you need to take on some very important responsibilities. These responsibilities, in part, include: taking care of personal medical and insurance concerns prior to participating, realistically and honestly evaluating your abilities, and helping in any way possible to make the outing or activity enjoyable for you and others. Initial___________ ASSUMPTION OF RISKS: By signing and initialing as appropriate, you are agreeing to the following: I have read the foregoing statement of risks together with any attachments associated with this outing and I acknowledge that I am acquainted with the dangers and risks of this outing. Also, I am of the appropriate skill level and physical condition to undertake the rigors of this class or outing. If I have any doubts of my physical or mental condition, I will seek medical advice. I have made a careful decision that I am willing to accept and assume all risks. Initial: _________ LIABILITY RELEASE: For the Associated Students permitting me to participate in the above-stated event, activity, or class, I understand and agree that situations may arise during the event which may go beyond the control of the Associated Students or of outing guides or other program participants. For myself and my personal representatives, assignees, heirs, and next of kin, or any of them, I AGREE TO INDEMNIFY AND HOLD HARMLESS, RELEASE, FOREVER DISCHARGE, AND AGREE NOT TO SUE the State of California, the Board of Trustees of California State University, California State University, Chico, the Associated Students of California State University, Chico, and their officers, employees, volunteers, agents, and other outing members (collectively "releasees") from any and all claims and liability arising out of strict liability or ordinary negligence of releasees which causes the undersigned injury, death, or property damage. If I file suit it will be in Butte County, CA, and if the suit is unsuccessful I agree to pay court costs and attorneys' fees for the defendants. I HEREBY WAIVE ALL SUCH CLAIMS WHICH I NOW OR MAY HEREAFTER HAVE AGAINST THE ABOVE ORGANIZATION OR PERSONS. I have read and understood the above and agree to be bound by it. Initial: _________ IMPORTANT NOTE: BEFORE SIGNING, READ CAREFULLY THE STATEMENTS ON THE FRONT AND BACK OF THIS PAPER. DO NOT SIGN-UP UNTIL YOU FULLY UNDERSTAND THIS STATEMENT AND THE RISKS ASSOCIATED WITH THIS OUTING. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK AT THE FOREBAY AQUATIC CENTER OFFICE, LOCATED AT THE THERMALITO NORTH FOREBAY STATE PARK IN OROVILLE, PHONE #624-6919. I HAVE READ CAREFULLY THIS FORM AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, A WAIVER OF CLAIMS, AN AGREEMENT NOT TO SUE, AND A CONTRACT BETWEEN MYSELF AND THE ASSOCIATED STUDENTS, AMONG OTHERS, AND FOR MYSELF AND FOR THE BENEFIT OF OTHERS DESCRIBED HEREIN, I SIGN IT OF MY OWN FREE WILL. Signature:___________________________________________________________________Date_____________________________ REFUND POLICY: No refunds will be given unless you call in and we are able to fill your spot. Keep your receipt.
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