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Campregistrationpacket

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NSU
MULTIMEDIA
CAMP
for Middle and High School students
ages 12 - 17
JUNE 17 – 29, 2019
• Parent/Guardian Contact Information
• Release and Waiver of Liability,
Assumption of Risk and Indemnity Agreement
• Office of Residential Life and Housing
Rules, Regulations, and Policies
• Photo Release Form
Page 2 of 8
Parent/Guardian Contact Information
Authorization to Release
Other than parent(s), please list additional people who are authorized to pick up the student:
Mother/Guardian/Co-Parent
FIRST NAME: ______________________________________ LAST NAME: _____________________________________
STREET ADDRESS: ____________________________________________________________________________________
CITY: ___________________________________ STATE:________________ ZIP CODE: ___________________________
HOME NUMBER: _______________________________ WORK NUMBER: _____________________________________
CELL PHONE NUMBER: _______________________________ EMAIL: _________________________________________
Father/Guardian/Co-Parent
FIRST NAME: ______________________________________ LAST NAME: _____________________________________
STREET ADDRESS: ____________________________________________________________________________________
CITY: ___________________________________ STATE:________________ ZIP CODE: ___________________________
HOME NUMBER: _______________________________ WORK NUMBER: _____________________________________
CELL PHONE NUMBER: _______________________________ EMAIL: _________________________________________
Emergency Contacts
NAME: ________________________________________ RELATIONSHIP: ______________________________________
PHONE NUMBER 1: _______________________________ PHONE NUMBER 2:________________________________
NSU Multimedia Camp
Page 3 of 8
THIS WAIVER AND RELEASE OF LIABILITY, INDEMNIFICATION, AND ASSUMPTION OF RISKS (the
“Release”) is executed by ____________________ (PARTICIPANT NAME) whose address is _____
_____________________________________________ (PARTICIPANT ADDRESS) in favor of NOVA
SOUTHEASTERN UNIVERSITY, INC., a Florida not for prot corporation (the “University”), whose
address is 3301 College Avenue, Fort Lauderdale, Florida 33314.
In consideration of my being allowed to participate in NSU MULTIMEDIA CAMP (the “Activity”) I
______________________________(PARTICIPANT NAME), the undersigned, for myself and on behalf
of my family, legal representatives, heirs and personal representatives if I am deceased, hereby release
and forever discharge the University, its trustees, ofcers, agents, and employees (hereafter collectively
the “Releasees”), from any and all liability for any injury, damage, claim, demand, action, loss, liability,
cost or expense (including, without limitation, reasonable attorneys’ fees) of any nature whatsoever,
which I, my family, legal representatives, heirs or personal representatives may now have or have in the
future against the Releasees on account of bodily injury, death, property damage, or accident of any
kind, arising out of or in any way related to my participation in the Activity, whether that participation
is supervised or unsupervised, and howsoever the injury or damage is caused, including any injuries
or damages suffered as a result of negligence on the part of the University, its trustees, ofcers, agents,
and employees. I acknowledge that my participation in this activity is purely voluntary and I am not
required as part of my academic program or otherwise to participate in the Activity.
In consideration of my participation, I agree to indemnify and hold harmless the University and the
other Releasees, from any and all causes of action, claims, demands, damages, liabilities, losses, costs
or expenses of any nature whatsoever (including, without limitation, reasonable attorney’s fees) asserted
against or incurred by the University and/or the other Releasees and arising out of or in any way
relating to my participation in the Activity.
I hereby acknowledge and agree that the Activity has inherent risks, and that I have full knowledge of
the nature and the extent of all risks associated with the Activity including, but not limited to:
1. Accidents or injuries of any kind while participating in the Activity;
2. Falling, tripping, or other incidental occurrences;
3. Reduced visibility; and
4. Inclement weather.
I further acknowledge that the above list is not inclusive of all possible risks associated with the Activity,
and that the above list in no way limits the extent or reach of this Release or the risks assumed, and that
I am voluntarily assuming all risks.
I understand that I will be solely responsible for any injury, death, loss or damage I sustain while
participating in the Activity, and that by this Release I relieve the University of any and all liability for
such injury, death, loss, or damage.
I hereby certify that I am in good health and that I have no physical limitations which would preclude
my safe participation in the Activity.
NSU Multimedia Camp
Waiver and Release of Liability, Indemnication,
and Assumption of Risks
Page 4 of 8
I understand that the University does not have medical personnel available at any time during the
Activity. I grant the University permission to authorize emergency medical treatment, including surgery,
and I agree that such action by the University shall be subject to the terms of this Release. I understand
and agree that the University assumes no liability or responsibility for any injury or damage that might
arise out of or in connection with such authorized emergency medical treatment.
I agree that if any provision of this Release is held to be invalid or unenforceable by a court of
competent jurisdiction, then the remaining provisions shall nevertheless continue in full force and effect.
I REPRESENT TO THE UNIVERSITY THAT (I) THE UNIVERSITY HAS INFORMED ME THAT BY SIGNING
THIS DOCUMENT I MAY BE RELEASING AND WAIVING CERTAIN LEGAL RIGHTS THAT I OTHERWISE
MIGHT HAVE, AND THAT I SHOULD READ THE DOCUMENT CAREFULLY AND UNDERSTAND IT FULLY
BEFORE SIGNING, (II) I HAVE READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS AND THE
EFFECT OF ITS TERMS AND PROVISIONS, (III) I SIGN THIS RELEASE AS MY OWN FREE ACT AND DEED,
(IV) WITH RESPECT TO THE MATTERS SET FORTH IN THIS RELEASE, NO ORAL REPRESENTATIONS,
STATEMENTS OR INDUCEMENTS OTHER THAN THOSE EXPRESSLY CONTAINED HEREIN HAVE BEEN
MADE TO ME BY THE UNIVERSITY, (V) I AM OVER EIGHTEEN (18) YEARS OF AGE AND FULLY
COMPETENT TO SIGN THIS RELEASE, AND (VI) I EXECUTE THIS RELEASE FOR COMPLETE AND
ADEQUATE CONSIDERATION, FULLY INTENDING TO BE LEGALLY BOUND BY THE SAME.
________________________________
Participant Name
________________________________
Participant Signature
________________________________
Participant Telephone Number
________________________________
Date
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Page 5 of 8
Once you have read the following items, please initial that you understand and will comply with the following rules,
regulations, and policies:
1. NSU is a smoke-free campus. Smoking is not allowed in the residence halls or on any other NSU property _______.
2. Alcoholic beverages may not be brought into the residence halls or on any other NSU property _______.
3. Firearms or any item considered to be a weapon is not to be brought into the residence hall or any
NSU property _______.
4. The possession, promotion, distribution, use, or sale of illegal substances is a violation of NSU policy. This includes
the trafcking and serving of substances represented as drugs to other persons. This also includes paraphernalia for
illegal drug use_______.
5. No alteration, damage, or removal of NSU property from the rooms or common areas should occur. Any changes
to set-up will result in a $10.00 per hour charge for reset and/or cost of replacement. Campers may be assessed a
nancial charge of $100.00 per occurrence if their participants move furniture out of the rooms _______.
6. NSU staff members have the right to inspect the rooms and all other areas in the assigned Residence Hall
at any time _______.
7. Windows should be kept closed or a $50.00 charge per occurrence will be assessed _______.
8. The camper’s parent(s)/ guardian will be assessed a charge of $75.00 per lost key and $25.00 per lost access
card after check-out. No camper may mail in or drop off lost keys/cards for charge reversal _______.
9. No one shall behave in a manner that harasses any other person or further serves to disrupt the peace and/or
comfort of other occupants. This includes, but is not limited to:
• Any words or acts, whether intentional, unintentional, negligent, or as a product of disregard for the safety,
rights, or welfare of others, which can cause physical or emotional harm, or which intimidate, degrade,
demean, threaten, haze, or otherwise interfere with another person’s right to comfort _______.
• Loud or aggressive behavior which disrupts the orderly functioning of NSU or any member of the
NSU community _______.
• Any conduct or action that constitutes a threat to the health or safety of the NSU community of those occupants
in assigned Residence Hall _______.
10. Occupants shall at all times be responsible for the conduct of their guests, in connection therewith; the organization
shall also be responsible for the conduct of all guests _______.
11. No pets or animals of any kind are allowed within any residence hall _______.
12. No family housing is available at this time children are not permitted to stay overnight in the residence halls at
Nova Southeastern University _______.
13. The camper and occupants shall comply with all directives and requests of a NSU representative acting in the
performance of his/her duties _______.
14. No one shall enter, or attempt to enter, any room, building, motor vehicle, or other form of property without proper
authorization or consent from NSU _______.
15. No re alarm shall be unnecessarily set off. Anyone found tampering with re extinguishers or alarm equipment,
blocking re exits, or impeding trafc ow in any other manner will be subject to a $500.00 ne _______.
Nova Southeastern University
Ofce of Residential Life and Housing
Rules, Regulations, and Policies
Page 6 of 8
16. The following items shall not be brought into rooms or into the common areas of the assigned Residence Hall:
barbecue grills, multi-outlet electrical plugs, candles, incense or other open ame items, non-approved extension
cords, halogen lamps, combustible materials, gasoline, or ammable petroleum powered vehicles _______.
17. Lounges, study rooms, reception lobbies, and other common areas are provided for the comfort and convenience
of all participants. Furnishings in outside and inside common areas may not be removed from those areas.
Participants, who take these items to their rooms or elsewhere, on or off campus, are subject to a $100.00 ne
Charges for loss or damaging not able to be assessed to a particular individual will be charged to the camper.
Charges for broken lounge furniture will result in nes to the camper.
Campers who are identied as being responsible for damages to residence hall furnishings, structures, or
equipment will be charged the appropriate labor, material, and administrative costs necessary to reimburse the
ofce of residential Life and Housing for the expenses involved.
These charges, however, may vary due to unforeseeable changes in the price of materials and labor. Other
damages to the assigned Residence Hall shall be charged according to cost of repair or replacement _______.
18. The following procedures must be followed in case of re:
When a re alarm is sounded, evacuate the assigned Residence Hall immediately and close the door when leaving
the room. Do not take the elevator – you may get caught in a power outage. There are stairwells located in each
residence hall to assist with emergency evacuation. When outside of the Residence Hall, remember to make your
way to the designated assembly point and do not interfere with the Town of Davie Fire Department, Town of Davie
Police, and any other authorities _______.
19. The procedures in the NSU Campus Safety and Trafc Handbook, available online at www.nova.edu/publicsafety/
forms/campus_safety_handbook.pdf must be complied with if a Hurricane Warning and/or other severe weather
conditions are declared by the U.S. Weather Bureau _______.
20. NSU is not liable for any loss or damage to the camper’s and/or the occupants’ property while on
NSU’s premises _______.
21. NSU reserves the right to evict any occupant or guest without refund when he or she violates any of these rules or
regulations _______.
22. This Contract shall be governed by, enforced and construed in accordance with the laws of the State of Florida.
With respect to any action instituted by either party relating to this Contract, the parties accept the exclusive
jurisdiction of the courts of the State of Florida, and agree that venue shall lie exclusively in
Broward County, Florida _______.
23. NSU shall not discriminate against any employee or participant in the performance of the duties, responsibilities
and obligations under this agreement because of race, age, religion, gender, national origin, marital status,
disability or sexual origin _______.
24. Each person by signing this agreement on behalf of either party individually warrants that he or she has full legal
power to execute this agreement on behalf of the party whom he or she is signing and to bind and obligate such
party with respect to all provisions contained in this agreement _______.
BY MY SIGNATURE I REPRESENT THAT I AM AT LEAST EIGHTEEN YEARS OF AGE OR,
IF NOT, THAT I HAVE SECURED BELOW THE SIGNATURE OF MY PARENT OR GUARDIAN AS WELL AS MY OWN.
________________________________
Signature of Participant
___________________
Date
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Page 7 of 8
________________________________
Signature of Parent or Guardian
___________________
Date
Signature of Parent/Guardian for Participants under eighteen (18) years of age:
I certify that I have custody of Participant or am the legal guardian of Participant by court order. I HAVE READ THIS
AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE
AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES.
I join with Participant in granting a release to Releasees as set forth in detail above
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Page 8 of 8
Release
I hereby give the unqualified right to Nova Southeastern University to take pictures and/or recordings of me and to
put the finished pictures/recordings to any legitimate use without limitation or reservation.
Signature: __________________________________________________________________________________________
Name Printed: ______________________________________________________________________________________
N Number: __________________________________________________________________________________________
Address: ____________________________________________________________________________________________
City: ____________________________________State:_________________ Zip Code: ___________________________
Project: ____________________________________________________________________________________________
Coordinator: ________________________________________________________________________________________
Date: _______________________________________________________________________________________________
*If subject is a minor under laws of state where modeling is performed:
Guardian Signature: _________________________________________________________________________________
Guardian Name:_____________________________________________________________________________________
Address: ____________________________________________________________________________________________
City: ____________________________________State:_________________ Zip Code: ___________________________
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Campregistrationpacket

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Completed 18 November 2019

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