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 1 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 · · · · · · · 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 · · · · · · · 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 · · · · · · · 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 · · · · · · 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! · Comfortable clothing & shoes (depending on the weather) · Swimsuit & towel (seasonal) · Flashlight (not essential - you don't need to buy one - bring one if you have it!) · Toiletry items (towels, toothbrush, toothpaste, soap, shampoo, etc.) · Bedding (sleeping bag or sheets & blanket) · Pillow · 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.
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