San Juan College JOLT Summer Teen Adventure Camp Registration 2016
How to Register:
Please bring this completed form to the Outdoor Equipment Rental Center
inside the Health and Human Performance Center at San Juan College.
4601 College Blvd. Farmington, NM 87402
Hours:
Monday through Friday 2-7 p.m. and Saturday 8 a.m. – 1 p.m.
A $100 deposit is due at registration to hold your place and can be paid at the Outdoor Equipment Rental Center
with cash, check, or credit card. The remaining $200 is due by the program’s start date and can be paid at the
Outdoor Equipment Rental Center or over the phone by calling (505) 566-3221. Refunds for cancellations are not
st
available after June 1 . Exceptions may be made for participants who request an exemption from the full cost of
the program through a written explanation of inability to pay. Exemptions will be granted only through a written
agreement that will involve the participant committing to a certain number of volunteer hours for outdoor
recreation programs in the fall 2016 semester. For example, if the participant can pay only $200 of the full cost of
the program, arrangements can be made for the participant to commit to 10 hours of service for future events
such as the Zombie 5K run in October 2016. If the participant does not follow through with volunteer hours, an
invoice will be mailed to the parent or legal guardian for the remaining amount due.
More Information:
Coordinator: (505) 566-3487 or [email protected]
Please print above each line:
_____________________________________________________________________________________
NAME OF TEEN PARTICIPANT Last Name
First Name
Middle Initial
_____________________________________________________________________________________
NICKNAME / NAME STUDENT GOES BY
_____________________________________________________________________________________
GENDER
DATE OF BIRTH
SOCIAL SECURITY NUMBER
_____________________________________________________________________________________
CURRENT AGE
GRADE FOR 2016-2017 SCHOOL YEAR
NAME OF SCHOOL
_____________________________________________________________________________________
ADDRESS
Street/PO Box
City
State
Zip
_____________________________________________________________________________________
TEEN’S CELL PHONE
TEEN’S EMAIL ADDRESS
ADULT T-SHIRT SIZE
_____________________________________________________________________________________
PARENT/GUARDIAN’S NAME
Work/Home/Cell (circle one) Work/Home/Cell (circle one)
_____________________________________________________________________________________
PARENT/GUARDIAN’S EMAIL ADDRESS
OCCUPATION/EMPLOYER
_____________________________________________________________________________________
EMERGENCY CONTACT #1 NAME
RELATIONSHIP TO TEEN
PHONE
_____________________________________________________________________________________
EMERGENCY CONTACT #2 NAME
RELATIONSHIP TO TEEN
PHONE
PROGRAM DATE SELECTION: All programs are one week, five full days from 8 a.m. – 5 p.m.
Transportation to and from program activities is provided. Lunch and snacks are the responsibility of the
participants. Choose from June 6-10th, July 18-22nd, July 25-29th, or August 1-5th
FIRST CHOICE: __________________________ SECOND CHOICE: _______________________________
MY DATES ARE FLEXIBLE: YES/NO __________
_____________________________________________________________________________________
AMOUNT I AM PAYING TODAY ($100 DEPOSIT IS DUE AT REGISTRATION, OR YOU CAN PAY IN FULL)
_____________________________________________________________________________________
SIGNATURE of person making payment
DATE
Participant Information:
Name:
Date of Birth:
Current level of physical activity: (Circle one)
Gender: M
F
Very
high
Height:
High
Weight:
Moderate
Low
Do you have any pre-existing medical/physical conditions, disabilities (temporary or
permanent)? If yes, identify and explain:
YES
NO
Do you have high blood pressure? If yes, are you taking medication? Please list.
YES
NO
Do you have any type of heart condition, or is there a history of heart conditions in your
family? If yes, identify and explain:
YES
NO
Are you currently taking medication (prescribed or otherwise, e.g. cold medicine)?
If yes, state what you are taking and what condition it is for.
YES
NO
Do you have any allergies, reactions to medication, or any other medical limitations?
If yes, identify and explain:
YES
NO
Please note: San Juan College’s JOLT Summer Teen Adventure Camp is unable to administer medications. The
participant must be capable of self-administering medicine. This form will be shared with the instructors of the
program so that they are aware of any medications, medical conditions, and/or allergies. The parent/guardian and
participant are responsible for ensuring that the participant has the appropriate medication with them during the
program (if applicable). Please note: Peanut products are not allowed. Out of consideration for students with
severe peanut allergies, please take care in sending snacks and lunch and do not send food with peanuts or peanut
products.
Signing below authorizes San Juan College to release this medical information to emergency and health care
providers.
_____________________________________________________________________________________
PRINTED NAME – PARENT/LEGAL GUARDIAN
SIGNATURE
PHONE
DATE
San Juan College JOLT Summer Teen Adventure Camp Waiver 2016
Acknowledgement of Program Information, Authorization for Medical Treatment, and Release of Liability
I, as the parent or legal guardian of the participant listed below, acknowledge that I have been
made aware of the following information about the JOLT Summer Teen Adventure Camp
program sponsored by San Juan College:
1. Participation in the JOLT Summer Teen Adventure Camp program may be physically or
emotionally demanding. By signing this Acknowledgement, I hereby state and affirm
that the participant is in good health and that he/she is not under a physician’s care for
any undisclosed medical or psychological condition that bears upon the participant’s
fitness to participate in the program’s activities. I have documented all known allergies
and medical conditions on the JOLT Summer Teen Adventure Camp registration form. I
acknowledge that out of consideration for students with severe peanut allergies, the
program requests that participants do not bring snacks or lunch with peanuts or peanut
products.
2. It is the responsibility of the parent or legal guardian to ensure that the participant has
safe and reliable transportation to arrive at the Health and Human Performance Center
between 7:50-8:00 a.m. on the scheduled dates of the program, and that the participant
has arrangements to leave the Health and Human Performance Center at 5:00 p.m. each
day.
3. Every participant age 14-15 must be signed in and out upon arriving and leaving the
program. A written letter must be on file if a parent chooses to allow his/her child, ages
14-15, to arrive and/or leave the program without supervision. Upon receipt of said
letter, this child will then be allowed to sign him or her self in and out. Parents assume
responsibility for their child when signed out; there are no protocols in place for your
child’s safety after sign out. If the parent or legal guardian of the child does not wish for
the child to leave the premises without the parent or without his/her explicit
permission, he/she must make that clear to the child. It is the responsibility of the
parent or legal guardian to ensure that the child knows who is allowed to collect them.
If there is a relevant restraining order or custody agreement in place, a copy must be on
file; contact the Coordinator of Outdoor Recreation at 566-3487. If a parent or legal
guardian receives a call from the JOLT program requesting pick up of the child, the
parent or legal guardian must make arrangements to collect the child promptly. The
JOLT program closes promptly at 5:15 p.m.
Authorization for Medical Treatment
In the event my child is injured or becomes ill while participating in the JOLT Summer Teen
Adventure Camp program, I hereby authorize San Juan College program staff to administer first
aid, arrange for emergency medical transportation and treatment and to release medical
information provided on the registration form to emergency and health care providers. I
understand payment of these damages or medical expenses is my responsibility.
Acknowledgement of Risk
The JOLT Summer Teen Adventure Camp program includes opportunities to canoe, kayak,
stand-up paddleboard, trek and rappel, climb and boulder on an indoor climbing wall, mountain
bike, disc golf, river raft, climb the Alpine Tower, net leap, and swing on the high elements of
the San Juan College High Endeavors Challenge Course. Each of these activities bears known
risks and unanticipated risks which could result in injury, death, illness, disease, emotional
distress, or damage to participants, to property or to third parties. The inherent risks of each
activity are listed below.
High Endeavors Challenge Course: This involves a variety of activities that often include warm-ups,
games, group initiative problems, high and low ropes course elements, climbing activities and other
rigorous physical adventure activities. These activities may involve balancing, heights, lifting, pushing,
and pulling and may be outdoors where rough, uneven footing, limbs and branches, insects, animals,
and possible inclement weather may be present. The level of participation in these activities is at all
times completely up to the individual’s choice.
Hiking, Rappelling, Rock Climbing, or Rock Face Climbing: The following describes some, but not all, of
related risks: Falls, heat-related illnesses including heat exhaustion and heat stroke, an ‘act of nature’
which may include rock fall, high winds and severe cold, and equipment failure. Certain foreseen and
unforeseen events can contribute to the unpredictability of these activities.
Indoor Climbing Wall: Climbing is a complex activity. The risk of injury for activities involved in using the
climbing wall is significant. Climbing and belaying terrain always creates potential for an accident.
Inherent risks of climbing include but are not limited to: Injury from falling up to 35 feet and impact
against the wall or landing surface; injury in the form of cuts, bruises, abrasions, muscle or tendon
strain; rope burns; failure to follow safety policies and procedures or follow directions from Indoor
Climbing Wall staff; the presence, actions or falls of other patrons; misuse of equipment or facilities in
the climbing area such as hanging on or swinging from ropes; injury caused by belayer (climbing partner)
negligence; excessive traversing too far to the side resulting in a pendulum fall; and failure to remove
hazardous jewelry or other sharp objects. The dangers and risks of participation could include, but are
not limited to: death, serious neck or spinal injuries which may result in complete or partial paralysis or
brain damage, serious injury to virtually all bones, joints, ligaments, muscles, tendons, and other aspects
of the muscular-skeletal system and serious injury or impairment to other aspects of my body, general
health and well- being. This risk includes but is not limited to: falling off or from the Indoor Climbing
Wall and hitting the floor, wall faces, people or any other equipment used in climbing, whether
permanently or temporarily in place; rope abrasion and entanglement; injuries resulting from falling
climbers, dropped items or broken holds; failure of ropes, knots, belays, slings, harnesses, climbing
holds, anchor points or any other part of the Indoor Climbing Wall.
Mountain Biking: Natural hazards do exist. Falls, collisions and overturns may occur. Vehicles, uneven or
unstable road surfaces/trails, trees, objects on the ground or in the roadway, equipment failure,
operator error, and the speed at which I travel can create hazards. Certain foreseen and unforeseen
events can contribute to the unpredictability of the activity. Wearing a helmet is a basic safety
precaution. Participants should ask about other potential hazards and recommended precautions and
procedures.
Watersports: Watercraft, including but not limited to canoes, kayaks, paddleboats, rafts, rowboats,
tubes, and the use of any equipment therewith bears known risks and unanticipated risks. The following
describes some, but not all, of those risks: Changing water flow or currents, submerged and semisubmerged objects, varying wind and weather conditions, the presence of other watercraft, the speed
at which I travel, the stability characteristics of a watercraft, and certain risks associated with this
activity including but not limited to collision, upset, overturn and sinking which can result in getting wet,
injured, exposed to the elements, drowned, personal property damaged or lost, and risks of travel
whether by car, van, bus, boat, or any other means. Wearing a U.S. Coast Guard approved floatation
device is a basic safety precaution.
Release of Liability
The activities and opportunities presented through the JOLT Summer Teen Adventure Camp
may expose participants to risks of property damage, personal injury, or death, and risks are
inherent to the activities. San Juan College cannot eliminate those inherent risks. The College is
not liable for accidents and injuries arising out of these inherent risks. Participants are not
covered by any College insurance for injuries arising out of those inherent risks.
I, as the parent and/or legal guardian, of the participant enrolled in San Juan College’s JOLT
Summer Teen Adventure Camp, for myself, all family members, or any other person claiming on
behalf of my child, agree to protect, defend, indemnify and hold harmless San Juan College and
its officials, agents and employees from any and all liability, damages, injury, claims, suits, liens
and judgments, of whatever nature arising from the participant’s participation in the College’s
JOLT Summer Teen Adventure Camp.
I hereby attest that I am authorized to sign this Acknowledgement, Authorization, and Release.
______________________________________________________________________________
PRINTED NAME – PARTICIPANT
______________________________________________________________________________
PRINTED NAME – PARENT/LEGAL GUARDIAN
______________________________________________________________________________
SIGNATURE
DATE
PHONE
______________________________________________________________________________
ADDRESS
STREET
CITY
STATE
ZIP
Publicity Release (optional)
I hereby voluntarily and without compensation authorize San Juan College to use my child’s
name and photograph in promotion of the College through radio, television, news media or any
and all other printed and electronic materials. This includes photographs taken by external
media photographers.
______________________________________________________________________________
SIGNATURE – PARENT/LEGAL GUARDIAN
DATE