Camper Waiver Packet
Child’s Full Name:
Date of Birth:
Mother’s Full Name:
Father’s Full Name:
Guardians Full Name:
Phone #: (
)
Email:
This packet is very important for the registration of each camper. The information we are asking for
will help the Super Kids Camp staff offer the best and safest camp possible. All of the requested
information must be completely filled out and returned prior to your camper attending Super
Kids Camp.
Return this waiver packet to the SSU Recreation Center or the SSU Student Center at the front desk.
After your registration packet is received, you will be emailed a confirmation letter. Information in
this packet details the day-to-day procedures of camp.
Payment Details
There is a one-time non-fundable registration fee of $40 per family. This fee is $20 for currently
enrolled SSU students, faculty, and staff.
Physical and online registration/ waiver forms need to be completed by the Wednesday prior to
the session being attended. Campers will not be able to attend camp until the packet is completed
and turned into the Sonoma State Recreation Center or Student Center.
A deposit can be made by the Wednesday prior to a session being attended to reserve your child’s
space. Deposits are per camper at $5 a day or $25 for a full week.
Payments need to be made the Wednesday prior to the session being attended to avoid a $20 late
fee.
There is a $35 refund fee for any transaction.
Check off List
Camper Information sheet
Medical Information & Certification of Health
Campus Recreation Climbing Wall Wavier
Release of Liability Wavier
Visual/Audio Image Release Form
Scanned ID photo page (anyone who is allowed to pick up your child
Camper Information Survey (Link in registration confirmation email)
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Camper Information Sheet
Camper’s Full Name:
Date of Birth:
Do you expect your child will have any special concerns about swimming at SKC?
(Circle) Yes No
If yes, please describe possible problems and any suggestions you may have to help with the
situation.
Will you be sending you child with a life jacket?
(Circle) Yes No
How would you rate your child’s general athletic ability for his/her age group?
(Circle) Above Average
Average
Fair
Does your child have any problems participating in large group activities?
(Circle) Yes No
If yes, do you have any suggestions on how we could help your child have a better time when
participating in these activities?
Is there anything you would like your child to accomplish while at Super Kids Camp? (Please
explain below)
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Medical Information & Certification of Health
This is to certify that _________________________________________________ is in good health; has had a
complete physical within the last year; has to had no recent exposure to a contagious disease and
has had no operation or serious illness since his/her last health examination. *If camper has had
serious illness or an operation since last examination, written permission must be obtained from a
physician for the child to attend Super Kids Camp.
Date of Last Examination:
Polio Immunization? (Circle) Yes No
Tetanus Shot Date:
Please list any allergies, disabilities, or conditions that should be known to the staff:
Has your child been taking any medications in the past 6 months that they will not be taking at
camp? (Circle) Yes No
If yes, please briefly explain:
Is your child currently taking any
medications?
Yes
No
Will your child need medications
administered at camp?
Yes
No
*Medications will be administered by the Camp Director as specified by parent and/or physician
Briefly describe the condition for which your child is taking medication:
Family Physician:
Phone:
Medical Insurance Company:
Policy#:
Exp:
Emergency Contact Name:
Emergency Contact Number:
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Medical Information & Certification of Health
I understand that I am required to have accidental medical coverage for the child listed on this
application and I verify that the information provided on my insurance policy is accurate and true.
In case of emergency and I cannot be reached, I authorize the staff of the Recreation Center to
obtain whatever medical treatment he/she deems necessary for the welfare of my child listed on
this application. I further understand and agree that I will be financially responsible for all charges
and fees incurred in the rendering of said emergency treatment, regardless of whether my medical
insurance would cover such charges and fees.
Signature of Parent or Guardian: ____________________________________________ Date: ____________________
Each parent or guardian, whose child participates in any phase of Super Kids Camp, assumes
responsibility for his or hers child’s health and physical well-being. Participation in Super Kids
Camp is on a voluntary basis. Therefore, neither the Sonoma State University, Sonoma Student
Union Corporation, nor the Campus Recreation department will accept responsibility for ill health
or injury sustained while participating in Super Kids Camp.
The staff of this department recommends that any person who participates in any phase of the
Super Kids Camp program undergo a physical examination prior to participation.
I verify that ________________________________________________________ is in good health and able to
participate in Super Kids Camp.
Signature of Parent or Guardian_______________________________________________ Date: ___________________
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Campus Recreation Climbing Wall Waiver
Name:
Date of Birth:
Address:
City/State/Zip:
Emergency Contact:
Phone #:
Release of Liability/Agreement Not to Sue for Climbing Wall Activities
I, ___________________________________, am aware that rock climbing/artificial wall climbing and bouldering
include certain risks including but not limited to the risk of injury or death. I am voluntarily and
participating in this activity and/or instruction about this activity with knowledge of the
dangers involved, and hereby agree to accept full responsibility for the risks and dangers
involved.
1.
2.
3.
4.
5.
6.
7.
I agree that I will not sue, or otherwise make any claim against Sonoma State University, Sonoma Student Union,
or their EMPLOYESS, agents (whether paid or volunteer), and contractors, for any loss, injuries, or damages
resulting from participation in rock climbing/artificial wall climbing and/or bouldering at Sonoma State
University’s Campus Recreation Climbing Wall.
I agree Sonoma State University’s Campus Recreation Climbing Wall, its employees, agents, and contractors, will
not legally be responsible for any loss, injury or damage of any kind to me, my heirs, or assigns, resulting from any
cause, including negligence.
I agree to use the climbing facilities according to the rules and regulation of Sonoma State University’s Campus
Recreation Climbing Wall.
I agree that as to any equipment, which I provide or borrow or rent from Sonoma State University’s Campus
Recreation Climbing Wall during any climbing/or other indoor our outdoor activity, I use at my own risk. I
understand and agree that Sonoma State University’s Campus Recreation Climbing Wall shall not be liable for any
loss, damage, or injury resulting from the use of said equipment. Sonoma State University’s Campus Recreation
Climbing Wall makes no warranties regarding said equipment.
To the fullest extent allowed by law I agree to RELEASE, INDEMNIFY and HOLD HARMLESS Sonoma State
University’s Campus Recreation Climbing Wall, its employees agents, and contracts from all actions or claims
which could be brought by myself, my heirs, assigns or personal REPRESENTIVE(s) for any loss, injury or
damaged sustained during and resulting from participation in rock climbing/artificial wall climbing and/or
bouldering at Sonoma State University’s Campus Recreation Climbing Wall including any loss, injury or damage
resulting from use of equipment.
The terms of this release shall also be binding as to any other persons, including family MEMBERS, heirs,
executors or administrators, and including any minors who may accompany me. I understand that this is a
binding contract which supersedes any other agreements or representations, and is not intended to provide a
comprehensive and complete release of liability, but is not intended to assert defenses which are prohibited by
law.
I am legally competent to sign the release; or, my parent or guardian has read and signed this release. I have
carefully read this agreement. I fully understand its contents and sign it on my own free will.
Participant Signature:
Date:
Must also be signed by parent or legal guardian if Participant is a minor, under 18 years of age.
Participant Guardian Signature:
Date:
If I am signing on behalf of a minor, in addition to the terms above, I also agree to Release, Hold Harmless and
Indemnify Sonoma State University’s Campus Recreation Climbing Wall, and its employees, agents, and
contractors for any claim the minor could bring. I agree to be solely responsible for any medical or legal
expenses incurred by the minor.
Accepted by Sonoma State University’s Campus Recreation Climbing Wall Staff Signature:
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Release of Liability – Promise Not to Sue – Assumption of Risk
Agreement to Pay Claims – Permission to use Visual Likeness
Page 1 of 2
Activities:
1. USE OF SSU RECREATION CENTER FACILITIES, EQUIPMENT, PROGRAMS, CLASSES, EVENTS AND SERVICES.
2. USE OF SSU POOL FOR CAMPUS RECREATION PROGRAMS.
Effective Locations and Time Periods:
1. RECREATION CENTER: DURING HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND INCLUDING
August 31, 2015.
2. SSU POOL: DURING CAMPUS REC SWIM HOURS OF OPERATION FROM THIS DATE (below) THROUGH AND
INCLUDING August 31, 2015 AS WELL AS DURING ANY OTHER TIMES DURING THIS PERIOD IN WHICH CAMPUS
RECREATION SPONSORS PROGRAMS/ ACTIVITIES IN THE POOL.
In consideration for being allowed to enter and use the Recreation Center and equipment, and participate
in its activities, including use of the SSU Pool, on behalf of myself and my next of kin, heirs and representatives, I
release from all liability and promise not to sue the State of California, the Trustees of the California State
University, California State University, Sonoma State University, and its employees, officers, directors, volunteers
and agents (collectively “University”) and the Sonoma Student Union Corporation and its employees, officers,
directors, volunteers and agents (collectively “Auxiliary Organization”) from any and all claims, including claims
of the University’s or Auxiliary Organization’s negligence resulting in any physical or psychological injury
(including paralysis and death), illness, property damage or economic or emotional loss I may suffer because of my
presence and/or participation.
I am voluntarily entering and using the Recreation Center and SSU Pool. I am aware of the associated risks
which include, but are not limited to, physical or psychological injury, pain, suffering, illness, disfigurement,
temporary or permanent disability (including paralysis), economic or emotional loss, death and/ or property
damage. I understand that these injuries or outcomes may arise from my own or other’s actions, inaction,
negligence, conditions related to the condition of the Recreation Center and SSU Pool. Nonetheless, I assume all
related risks, both known or unknown to me, of my presence and participation.
I agree to hold the University and Auxiliary Organization harmless form any and all claims, including
attorney’s fees and/ or damage to my personal property that may occur as a result of my presence and/or
participation in Recreation Center and SSU Pool facilities, equipment, programs, classes, events, and services. If I
need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I
am aware and understand that I should carry my own health insurance.
I grant permission for Campus Recreation staff to take, and make public, visual/ audio images of me. I agree
that Campus Recreation owns the images and all the rights to them. Without notifying me the images may be used
in any manner or media including, but not limited to, University --- sponsored websites, publication, promotions,
advertisements, and posters. I waive any right to inspect, approve, or be compensated for the use of such images.
As of the date below, I am 18 years or older. I understand the legal consequences of signing this
document, including that I (a) release the University and the Auxiliary Organization from all liability, (b)
promise not to sue the University and the Auxiliary Organization, and (c) assume all risks associated with
my presence and participation in the Recreation Center and SSU Pool.
I understand that this document is written to be as broad and inclusive as legally permitted by the State of
California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining
terms. I have read this document, and I sign it freely. No other representations concerning the legal effect of this
document have been made to me.
Participant Signature: ________________________________________________________________ Date: __________________________
Participant Name (Print): ____________________________________________________________Date: ___________________________
NOTE: (If under 18 years of age as of the date above, a Parent or Guardian Signature is required on Page 2.)
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Release of Liability – Promise Not to Sue – Assumption of Risk
Agreement to Pay Claims – Permission to use Visual Likeness
Page 2 of 2
This page is only required if participant is under 18 years of age.
If participation is under 18 years of age as of the date on Page 1, a Parent or Guardian Signature is required:
I am the parent or legal guardian of the person named on page 1. I understand the legal consequences of signing
this document, including that I (a) release the University and the Auxiliary Organization from all liability on my and
the Participant’s behalf, (b) promise not to sue on my and the Participant’s behalf, (c) assume all risks of the
Participant’s presence and participation. I allow my dependent to be present and to participate. I understand that I
am responsible for the obligations and acts of the Participant as described in this document. I agree to be bound by
the terms of this document.
I have read this two---page document, and I am signing it freely. No other representations concerning the legal
effect of this document have been made to me.
Signature of Minor Participant’s Parent/ Guardian: ________________________________________ Date: _________________
Name of Minor Participant’s Parent/ Guardian (Print): ____________________________________ Date: _________________
Minor Participant’s Name (Print): ____________________________________________________________ Date: _________________
Date Minor Participant will turn 18 years old: _______________________________
Minor Participant’s SSU ID# (if applicable): __________________________________
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Visual/Audio Image Release Form
I grant permission to Sonoma State University, its employees and agents, to take and use
visual/audio images of me. Visual/Audio images are any type of recording, including
photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips
or accompanying written descriptions. SSU will not materially alter the original images. The
sponsored websites, publication, promotions, broadcasts, advertisements, posters, and theater
slides, as well as for non-University uses. I waive any right to inspect or approve the finished
images or any printed or electronic matter that may be used with them. I release SSU and its
employees and agents, including any firm authorized to publish and/or distribute a finished
product containing the images, from any claims, damages, or liability which I may ever have in
connection with the taking of and/or use of the images or printed material used with the
images. I am at least 18 years of age and competent to sign this release. I have read this release
before signing. I understand its contents, and I freely accept the terms.
Printed name of subject:
Signature of subject:
Parent/guardian if under 18 years of age:
Telephone and email address:
Address (optional):
Date:
Year in School:
Project name: Super Kids Camp
Photographer’s name and contact information: Super Kids Camp (707) 584-4386
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Photo ID page NEEDED!!!
Please copy as many photo ID’s on a blank page
of paper with your child/children’s name, which
will be added to the end of the packet. Only one
page of ID’s are needed per family. Please make
sure all photos are legible. Staff will be checking
ID’s at pick-up time. Children will only be
able to leave with an adult that has a
matching ID. If you have any questions about
this please contact the Directors.
On our blog we have an example of what we are
looking for!
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Camper Information Survey
Order #: _____________________________
Parent/Guadrdian Information: ________________________________________
Name(s): ________________________________________________________
Day Time Phone: ___________________________________________________
Campus Affiliation:
N/A
Faculty
Staff
Student
Emergency contacts (please list in order of contact preference.) Be sure to include
name and phone numbers for each person.
________________________________________________________________
________________________________________________________________
Physican Name: ___________________________________________________
Physician Phone: __________________________________________________
Medical Insurance Company: ________________________________________
Camper #1 Information
Camper name: ___________________________________________________
Age: ___________________________________________________________
Grade: __________________________________________________________
Gender: Female
Male
Medial Insurance Policy #:___________________________________________
T-shirt Size: ______________________________________________________
Will you be sending your child with a life vest?
Yes
No
Allergies:_________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________________
Please describe your child's general athletic and swimming ability compared to
other children his/her age:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Please list any physical or emotional health concerns that our staff should be
aware of:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Camper #2 Information
Camper name: ___________________________________________________
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Age: ___________________________________________________________
Grade: __________________________________________________________
Gender: Female
Male
Medial Insurance Policy #:___________________________________________
T-shirt Size: ______________________________________________________
Will you be sending your child with a life vest?
Yes
No
Allergies:_________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________________
Please describe your child's general athletic and swimming ability compared to
other children his/her age:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Please list any physical or emotional health concerns that our staff should be
aware of:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Camper #3 Information
Camper name: ___________________________________________________
Age: ___________________________________________________________
Grade: __________________________________________________________
Gender: Female
Male
Medial Insurance Policy #:___________________________________________
T-shirt Size: ______________________________________________________
Will you be sending your child with a life vest?
Yes
No
Allergies:_________________________________________________________
________________________________________________________________
________________________________________________________________
Please describe your child's general athletic and swimming ability compared to
other children his/her age:___________________________________________
________________________________________________________________
________________________________________________________________
Please list any physical or emotional health concerns that our staff should be
aware of:
_______________________________________________________
________________________________________________________________
________________________________________________________________
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