Fill - Free fillable Individual Participant Release 2017 (University of West Florida) PDF form

University of West Florida, Office of Recreation and Sports Services

STATEMENT OF ASSUMPTION OF RISK, INFORMED CONSENT, and RELEASE OF LIABILITY

Argo Adventure Camp

I, (print

participant’s

full name), the undersigned

participant, (

or in the event the undersigned is under eighteen (18) years of age, the undersigned’s parent or

guardian), have

actual knowledge and conscious appreciation of the particular risks involved in sports activities

organized by the University of West Florida. I acknowledge that the activities I will be participating in may involve

strenuous physical activity, physical interaction with other participants, travel, exposure to inclement weather and

other dangers, which may result in injuries to me, ranging from minor to severe, including serious permanent

disability, paralysis, or death. These types of injuries may result from my own actions, the actions or inactions of

others or a combination of both.

Other specific risks that may arise from my participation in these activities may also include, but are not

limited to abrasions, bruises, concussions, cuts, dehydration, dental/oral injury, dislocations, eye injury,

fungal/bacterial infection, fractures, head injury, heat illness, lacerations, ligament tears, muscle strain, scratches,

spinal injury, sprains, and vision loss.

I understand that participating in sports activities require a minimum level of fitness for safe

participation. I warrant that I am physically able to participate and have no physical condition that would prevent

my participation in this activity. I acknowledge that it is my responsibility to secure appropriate personal

medical insurance and no such coverage is provided or implied by the University of West Florida.

I understand that the rules and instructions involved with this activity are designed for my safety and

protection and I hereby undertake to abide by all such rules and instructions. I understand that my failure to

adhere to the rules and instructions involved with this activity may result in my being removed from this and

other such activities presently and permanently.

I authorize the University of West Florida, acting for and on behalf of the University of West Florida Board of

Trustees (“University”) and those acting pursuant to its authority to record my likeness and/or voice on a video, audio,

photographic, digital, electronic or any other medium; use my name and biographical material in connection with such

recordings; and use, reproduce, exhibit, and/or distribute my name, biographical material, and such recordings on any

medium (e.g., print publications, video, internet, etc.) for a variety of promotional, advertising, educational, and/or other

lawful purposes. I agree to release the university from all liability related to the recordings and waive any claims or

rights of compensation or ownership regarding such uses, and agree and understand that all such recordings shall remain

the property of the University.

In consideration of my participation, I agree to forever hold harmless, covenant not to sue, release and

discharge the State of Florida, the Florida Board of Governors, the University of West Florida Board of Trustees,

the University of West Florida, and all other sponsors and their respective officials, employees, agents, assigns,

volunteers, and guests (hereinafter referred to as “Released Parties”) from any and all liability resulting from

the ordinary negligence of those involved, including Released Parties. I further a gr e e t o f o r ev er save and

hold harmless the Released Parties from any claim or lawsuit by me, my spouse, my family, estate, heirs, or

assigns, arising out of my participation in the program offered or sponsored by the University of West Florida,

including all claims, demands, actions, complaints, suits or other forms of liability that shall arise out of or by

reason of, or be caused by use of my photograph, likeness or voice.

I expressly agree that this agreement is intended to be as broad and inclusive as permitted by the laws of

Florida and that if any portion is held to be invalid, it is agreed that the balance of the agreement shall continue

in full legal force and effect.

I acknowledge that in executing this Statement of Assumption of Risk, Informed Consent and

Release of Liability, I have read this statement, understand its contents, had the opportunity to ask questions about

it and sign it of my own free will and choice.

Knowing the risks described, and in consideration of being permitted to participate in the program, I

agree, on behalf of myself, my family, heirs and personal representatives, to assume the risks and responsibilities

surrounding my participation in the Program.

Signature of Participant or Parent/Guardian Date

PERMISSION/WAIVER FOR DISPENSING OF MEDICATION:

It is required by the University of West Florida, as a condition to administer any prescription medication, that the

medication be authorized by a physician, dentist, or other licensed prescriber. It is understood that prescription

medication is administered solely at the request of and as an accommodation to the undersigned parent/guardian. I

request that

_______________________________________________(Printed Name of Participant)

Receive

name of medication dosage of medication

For the period from ____________ to ________________ at ___________ (Date/Time(s))

Physician’s description of any anticipated reaction of child to the medications (if any):

__________________________________________________________________________________________

I give permission to UWF to dispense medication to the camp participant named above while she/he is participating in a

UWF program for which an appropriate authorization has been provided. I understand that UWF does not have medical

personnel on staff to assist in the administration of medication for camp participants and that medication will be dispensed

by the camp staff; I understand that UWF will not and cannot assess the need for, or assume any risks associated with, the

administration of any medication. I understand that the administration of any medication involves a risk of injury, which

ranges from minor to catastrophic and that it is impossible to eliminate such risks. Despite this knowledge, I covenant not

to sue and release UWF and each of its trustees, employees and agents from all liabilities, claims, and demands for injury or

loss that I and/or the above named participant may now or in the future have, resulting from the dispensing and/or

administration of medication while in a UWF program or any disclosure relating to medication administered. I understand

the prescription medication must be brought to camp in the original container appropriately labeled by the pharmacy or

physician, stating the name of the participant named above, the medication, and dosage.

______________________________________ ________________________________________

Parent Printed Name Signature Date

AUTHORIZATION FOR MEDICAL TRANSPORATION AND TREATMENT:

If my child is injured in an accident or becomes seriously ill while participating in a UWF camp program, I authorize UWF

to arrange for the transportation of my child to a licensed emergency medical care facility to receive prompt treatment.

Furthermore, I authorize the medical personnel at the facility to provide such treatment to my child as is indicated by the

nature and extent of his or her injury and that is in accordance with the protocols of standard medical practice. Finally, I

accept full financial responsibility, for all costs, charges, and fees associated with the transportation of my child and for

the treatment provided by the medical care facility to my child and absolutely and unconditionally agree to indemnify and

to hold UWF harmless from all such costs, charges, and fees.

______________________________________ ________________________________________

Parent Printed Name Signature Date

Known Allergies:

Special Needs/Requests:

Code of Conduct

While every camper at Argo Adventure Camp deserves the most rewarding and fulfilling experience, the Camp

Directors, Counselors, Staff, and University of West Florida must expect each camper to abide by specific rules, regulations,

and expectations of behavior. The following outlines how campers should act while at Argo Adventure Camp and what

disciplinary processes may incur should a camper not abide by the expectations given to them.

1. Campers are expected to accept other campers, counselors, staff, and all related to the University of West Florida.

Negativity directed towards any individual will not be tolerated. This includes: put-downs, teasing, excluding, joking,

aggravating, etc.

2. Ethical or racially charged jokes, teasing, slurs, or put downs are not permitted. Campers are expected to welcome

diversity and to learn from the differences other campers may have.

3. Campers will refrain from touching others in harmful or inappropriate ways.

4. Fighting, whether verbally or physically, will not be tolerated.

5. Argo Adventure Kids Camp prohibits foul language of any kind. We are a fun environment that discourages negative

language of all kinds.

6. Campers must follow directives from the Camp Directors, Counselors, and Staff at all times. Failure to comply with

directives will result in disciplinary measures.

7. Closed toe and closed heel shoes are required at all times.

8. Appropriate clothing and swimwear are required for participation in activities.

9. Campers must be attentive to all activity directions and safety rules.

10. Campers must never leave their group or counselor without permission.

Disciplinary Process

We at Argo Adventure Kids Camp want each camper to have a great experience at camp. We understand that campers

may have “off” days. However, overall good behavior is expected from every camper to ensure the safety and pleasure of all

participants. The following is a guideline of how Camp Counselors will confront unwanted, negative behavior from any

camper:

1. Warning: The camper will get a verbal warning of their inappropriate behavior.

2. Restriction: After a warning, if the behavior persists, the camper will sit out from activity for no more than 15

minutes.

3. Reporting: Should a camper persist in their behavior or escalate their behavior, the counselor will refer them to the

Camp Director who may have the camper refrain from an entire activity. This may include the camper spending time

in the Recreation and Sports Services Office.

4. Dismissal: If behavior proves too severe or intense, the Camp Director will request the parent/guardian to pick up the

camper. If parent/ guardian cannot be reached, an emergency contact must fill in. Should the behavior of the camper

prove extreme, the camper may be asked not to return to camp the following day or may be revoked from camp

without refund.

Camper Signature Date

Parent Signature Date

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Individual Participant Release 2017 (University of West Florida)

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