COCC Summer Youth Camp
Information and Release Form
Student’s Name:
_
Age student will be at beginning of Camp: Birth date: / / _
Parent Name(s):
Mailing
Address:
ZIP:
Day Time Phone:
Work
Phone:
E-mail
address:
How
did you hear about COCC Youth
Camp?
In
case of Emergency, COCC should contact:
Name
&
Phone
#
In consideration for providing my child the opportunity of participating in youth camp, while fully recognizing the
dangers and hazards inherent in participating in youth camp activities and any related transportation to and from
activity events, to the fullest extent allowed by law, on behalf of myself and my minor child, I hereby
voluntarily agree to waive and discharge any and all claims of whatever nature and release from liability,
fully and finally, for myself, my child, our estates, our heirs, our administrators, our executors, our assignees, our
successors, and to release, exonerate, discharge and Hold Harmless the Central Oregon Community College,
its Board of Directors, the individual members thereof, and all officers, agents, employees, volunteers, and
representatives from any and all liability, claims, causes of action, or demands including attorneys fees, arising
out of any injuries of any kind, whether physical or emotional, to me,
my child,
or to our property, or losses of any
kind which may result from or in connection with my child’s participation in computer camp up to and including
injuries stemming from the negligence of the College or
its employees or agents. I further certify and represent that I have the legal authority to waive, discharge,
release, and hold harmless the released parties on behalf of my child.
In the event that my child may require emergency medical treatment while participating in the aforesaid
activities, I authorize the College and its employees to secure the services of a physician or hospital, and to
incur the expenses for necessary services in the event of an accident or illness and I will provide for the
payment of these costs.
This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part
of any provision of this Agreement is held to be invalid or legally unenforceable for any reason, the remainder of
this Agreement shall not be affected thereby and shall remain valid and fully enforceable.
I certify that I have read this release and fully understand its contents. I have read this Agreement in its
entirety and I freely and voluntarily assume all risks of such hazards and notwithstanding such, I agree to
participate with my child(ren) in this activity.
Signature
of
Parent/Guardian
Date:
COCC Community Learning
2600 NW College Way Bend OR 97703 541 383 7270 www,cocc.edu/ContinuingEd
Medical Information:
Known
allergies
(drug
or
natural)
Special
medication
being
taken
Date
of
last
tetanus
shot
History
of
heart
condition,
diabetes,
asthma,
epilepsy,
or
rheumatic
fever
Any
physical
restrictions
Other
conditions
Family
Doctor
Insurance Company Name
Policy #
Any
addition
information
you
would
like
us
to
know
about
your
child
Email
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