CAMP/CLINIC DEPARTURE RELEASE FORM
Camper name ____________________________________________
First
MI
Last
Parent(s)/legal guardian(s):
Date ______________________
________________________________________________________
________________________________________________________
The camper named above may be released to the following people. Please note:
•
Camper will only be released to individuals listed below.
•
All individuals must present picture identification when picking up camper.
1. _________________________________________________
Name
________________________
Telephone number(s)
2. _________________________________________________
Name
________________________
Telephone number(s)
3. _________________________________________________
Name
________________________
Telephone number(s)
4. _________________________________________________
Name
________________________
Telephone number(s)
5. _________________________________________________
Name
________________________
Telephone number(s)
When picking up the camper please sign and date next to the weekday listed.
Monday
______________________________________________
Signature of person camper is being released to
__________
Date
Tuesday
______________________________________________
Signature of person camper is being released to
__________
Date
Wednesday
______________________________________________
Signature of person camper is being released to
__________
Date
Thursday
______________________________________________
Signature of person camper is being released to
__________
Date
Friday
______________________________________________
Signature of person camper is being released to
__________
Date
Saturday
______________________________________________
Signature of person camper is being released to
__________
Date
Sunday
______________________________________________
Signature of person camper is being released to
__________
Date
MEDICAL INFORMATION FORM
This form must be received prior to the camp in order for the camper to participate.
Please complete this form for each camper:
Camper’s name __________________________________________________
First
MI
Last
Summer camp _____________________________
Birth date ___________
Date(s) ___________________________________
Parent(s) or legal guardian(s) _____________________________________________________________
Home phone ______________________________
Work phone _______________________________
Emergency contact person _______________________________________________________________
Home phone ______________________________
Work phone _______________________________
Physician _________________________________
Phone ____________________________________
Please provide the following information regarding camper’s health:
Medical allergies ______________________________________________________________________
Food allergies _________________________________________________________________________
Diabetes _____________________________________________________________________________
Asthma ______________________________________________________________________________
Current medications ____________________________________________________________________
_____________________________________________________________________________________
Please specify any other health-related conditions of camper: ___________________________________
_____________________________________________________________________________________
We strongly recommend a physical exam prior to attending a summer camp or other athletic event
sponsored by the Jim Montgomery Hockey Camp LLC.
I/We certify that the above camper is in good health and able to participate in this program.
Parent/guardian signature __________________________________________
Date _______________
Parent/guardian signature __________________________________________
Date _______________
RELEASE OF LIABILITY
PARENTAL PERMISSION FORM/ACKNOWLEDGMENT OF RISK AND RELEASE
THIS DOCUMENT MUST BE SIGNED BY THE PARENT OR LEGAL GUARDIAN OF PERSONS UNDER THE
AGE OF 18 PARTICIPATING IN AN EVENT HELD UNDER THE AUSPICES OF THE UNIVERSITY OF DENVER
(THE “UNIVERSITY”) AND JIM MONTGOMERY HOCKEY CAMP LLC (THE “OWNER”) IF THE
PERSON PARTICIPATING IN THE EVENT IS 18 YEARS OF AGE OR OLDER, THEN THE PARTICIPANT MUST
SIGN THIS DOCUMENT.
***
The individual named below as “Participant,” if over the age of 18, or his parent or legal guardian if the Participant
is under the age of 18, hereby acknowledges that he or she authorizes Participant to participate in the Jim
Montgomery Summer Hockey Camp (the “Camp”), and further acknowledges his or her full understanding and
appreciation that there are risks of damage or injury associated with participation in the Camp, including those risks
normally associated with the sport of ice hockey. The person signing further acknowledges his understanding that
Events held other than on the campus of the University of Denver are not subject to the same degree of supervision
and control by the University as events occurring on its campus and that, absent the signing of this document by
Event Participants or their parent or legal guardian, Colorado Seminary likely would not sponsor or offer Events
taking place off campus.
The person signing this document also recognizes and understands that photographic and film production occurs at
various times throughout the Camp, and hereby permits the Owner, its agents, assigns and producers to freely use
any such photographs and film that may contain the Participant’s image, without compensation, in promotion of the
Camp or any future events related or unrelated to the Camp in any media, including television programming.
The person signing this document hereby represents that he or she has advised the University and the Owner of any
facts known to him or her which would make the Participant more susceptible to injury or risk of injury as a result of
participating in the Camp than would be the average person of the same age. Any parent or legal guardian signing
further represents that he or she has thoroughly explained to the minor Participant the risks associated with
participating in the Camp using language appropriate to the age and intellectual capacity of the Participant.
By signing this form, the Participant, or his parent or legal guardian, on behalf of himself, his heirs, assigns, legal
and personal representative(s), agrees to assume all risks and responsibilities surrounding Participant’s participation
in the Camp and further to release the University, the Owner, and all departments and divisions thereof from any
claims, demands, actions, causes of action, lawsuits, expenses, or losses (including court costs and all reasonable
attorney fees) he or she may incur on account of property damage or personal injury (including death) arising out of
or attributable to Participant’s travel to or participation in the Camp, whether such property damage or personal
injury or death is caused by the negligence of the University, the Owner, their trustees, officers, employees or
agents, or otherwise.
Executed this _____ day of _________________________, 2014.
_________________________________________
PRINTED NAME OF PARTICIPANT
_________________________________________
SIGNATURE OF PARTICIPANT (IF 18 OR OLDER)
As the parent or legal guardian of the above-named minor, I hereby represent and warrant that I have authority to
sign this Release of Liability on behalf of said minor, and agree to indemnify the University and the Owner, as well
as their respective officers, agents, successors and assigns for any lawsuit brought by or on behalf of the abovenamed minor.
SIGNATURE OF PARTICIPANT’S PARENT OR LEGAL GUARDIAN
IF PARTICIPANT IS UNDER 18 YEARS OF AGE
______________________________________________________
MEDICAL CONSENT FORM
This form must be received prior to the camp in order for the Camper to participate.
Child’s name (“Camper”) _______________________________________________________________
First
MI
Last
Camp: Jim Montgomery Summer Hockey Camp
Date(s) ____________________
I understand that the Jim Montgomery Hockey Camp LLC (the “Owner”) does not provide medical
insurance of any kind. I hereby acknowledge and agree that I will look solely to my own medical
insurance for medical costs and expenses incurred as a result of any accidents and injuries that occur to
the above Camper while participating in the Jim Montgomery Summer Hockey Camp (the “Camp”).
________________________________________________________
Parent/legal guardian
___________________________
Date
PRIVATE MEDICAL INSURANCE
Please supply the following information, if applicable:
Camper’s SSN (if applicable) _______________________________
Birth date __________________
Insurer _________________________________________________
Policy # ___________________
Group # __________________________________
Plan # ___________________________________
Policyholder name ________________________________________
Relationship _______________
Preferred hospital and/or physician _______________________________________________________
CONSENT TO MEDICAL TREATMENT
The undersigned parent(s) or legal guardian(s) of the above-named Camper do hereby consent and grant
to the Colorado Seminary (University of Denver), Division of Athletics and Recreation, the Owner, and
summer sport camp staff, coaches, and trainers or medical physician(s) the authority to seek, obtain,
approve, and provide any medical treatment for the above-named Camper that in their judgment is
necessary for the health and well-being of the Camper during his or her participation in the Camp. The
undersigned further give the above-referenced individuals and entities permission to secure emergency
medical and/or surgical treatment to the Camper and to transport the Camper to appropriate medical
facilities if necessary while attending and participating in the Camp. The undersigned further agree to
release, hold harmless, and indemnify Colorado Seminary (University of Denver), Division of Athletics
and Recreation, the Owner, and summer camp employees, staff, coaches, and trainers from any claims or
damages which may arise from any accident or loss, however caused.
Parent/guardian signature __________________________________________
Date _______________
Parent/guardian signature __________________________________________
Date _______________