Ultimate Team Camp Form – Ultimate Team Camps

General Camper Information

Camp Attending:

HIGH SCHOOL:

CAMPER'S NAME:

Month

Day

Year

Age When Camp Starts

Address

City

State

Zip

Players Cell Phone

Emergency Contact Information

Emergency Contact Name

Relation:

Phone number of emergency contact person

HEALTH & GENERAL HISTORY: If the camper should be restricted from any activity please note:

If the camper will be taking medication during camp, please indicate name of drug and dosage:

Please identify any medical condition or medical history that would require special attention:

Health History Information

Please indicate any of the following necessary medical information

HOLD DOWN CTRL Key to Indicate Multiple Selections

Common Conditions

Immunizations

Allergies

Drug Reactions

Please explain any selections of "OTHER" or any special circumstances from selections above:

HEALTH INSURANCE INFORMATION

Physician's Name:

Telephone

Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

Release of Liability

As the parent (guardian) of the named camper give permission to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named above, before taking this action. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment. I further agree that my child can receive over-the-counter remedies if necessary. (Tylenol, Sudafed, etc.) Please give special instructions above if you do consent to your child receiving over-the-counter medications.

I HAVE READ THE POLICIES AND FULLY UNDERSTAND MY OBLIGATIONS STATED THEREIN AND ALSO THE RIGHTS
OF Ultimate Team Camps, AND HERBY AGREE TO ACT IN ACCORDANCE.

I also agree that my child may be transported by bus and/or camp vehicle to an off-site medical center or for emergency medical treatment. The undersigned further expressly agrees that the attached waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

In consideration of my minor child/ward (“my child”) being allowed to participate in this sport camp program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. The risk of serious injury from the sports activities involved in this program is always present due to the nature of the sport (s); and

2. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s participation; and

3. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation.

If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE,

INDEMNIFY, AND HOLD HARMLESS the Camp, Ultimate Team Camps, its affiliates, officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, regarding my child and/or arising from his/her activities, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except for willful misconduct, or otherwise to the fullest extent of the law. I HAVE READ THIS HEALTH FORM AND RELATED CERTIFICATIONS, THE RELASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Ultimate Team Camps/UTC Fire COVID-19 Statement

Ultimate Team Camps/UTC Fire has put in place measures to reduce the spread of COVID-19. However, notwithstanding any such efforts, it is simply not possible to guarantee that COVID-19 is not present nor to prevent you or your child from becoming exposed to, contracting, or spreading COVID-19. By participating in any of the Ultimate Team Camps/UTC Fire activities, you and your child are exposed to the risk of contracting or spreading COVID-19. By participating in certain activities associated with greater rates of disease transmission, you and your child are exposed to a higher risk of contracting or spreading COVID-19. Activities that may pose a higher risk for COVID-19 include (but are not limited to): transportation, practices, gameplay, sleep quarters and any activity where people are closer than 6 feet apart.

Assumption of Risk

I understand that my child’s participation with Ultimate Team Camps/UTC Fire is voluntary and is not required. By signing below, I acknowledge I have carefully read the above; I understand the risks of COVID-19 associated with participating in activities in-person. I voluntarily assume such risks, including the risk of serious illness, debilitating injury, or death to my child and myself. By signing below, I further acknowledge I understand the risk of exposure to, contracting, or spreading COVID-19 may result from the acts of or omissions of myself and others, including but not limited to Ultimate Team Camps/UTC Fire employees, volunteers, program participants and/or other individuals who may be present in the facilities or in attendance at Ultimate Team Camps/UTC Fire events. I knowingly assume the risks of COVID-19.

By checking this box I am certifying I have legal ability to consent for the camper. I agree that all information provided is accurate to the best of your knowledge. I am over the age of 18 and I allow Ultimate Team Camps to act in the best determined interest of my child should there be contact not be possible or available.

Parent/Guardian Signature:

Date: