SV New Family School Year 2019-2020

Scott Valley Funderblast Registration Form
School Holiday 2019-2020

Are you a member of Scott Valley Swimming & Tennis Club? *

Yes No

* Indicates required field

Parent/Guardian 1 - Name *

First

Last

Parent/Guardian 1 - Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Parent/Guardian 2 - Name *

First

Last

Parent/Guardian 2 - Email *

Address (if different) *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Cell Phone Number *

Work Phone Number *

Child 1 - Name *

First

Last

Age *

Date of Birth *

Child 2 - Name *

First

Last

Age *

Date of Birth *

Payment Method *

Cash Check Bill SVSTC Member Account

We will email you a confirmation with the total amount due within the next couple days. Thanks!

In Case of Emergency (ICE) Contact - Other than Parents *

First

Last

ICE Phone Number *

Permitted To Pick Up my Child *

First

Last

Phone Number *

Family Doctor *

Phone Number *

Insurance Carrier and/or Medial Plan *

Any Allergies? *

--> Is it a true medical allergy or a dietary preference? *

Medical Allergy Dietary Preference

Does Either Child Require an Epi-Pen? *

Yes No

Any additional medical info we should know about? *

Please list all current medications regardless of whether it needs to be taken at camp or not: *

Any activities to be restricted for health reasons: *

Any additional info we should know (e.g. my child has a tendency to wander off etc.) *

WAIVER AND RELEASE OF LIABILITY FOR MINORS. In consideration for permission to participate in any activity at Camp Funderblast (“Camp”) today and on all future dates, I, for myself, and on behalf of the minor child(ren) identified above (“Participant”), our heirs, personal representatives and/or assigns, do hereby release, waive, discharge, and covenant not to sue Funderblast LLC, Homestead Valley Community Association, Scott Valley Swimming & Tennis Club, the County of Marin, or Cascade Canyon School a tenant of Saint Rita’s Catholic Church (collectively referred to herein as, “Indemnified Parties”), their directors, officers, owners, employees, counselors or volunteers, from liability for any and all claims for personal injury, illness, death, property damage, or any other claim, including but not limited to claims arising out of the negligence of Indemnified Parties, their employees or their agents. This waiver and release of liability applies to all Camp activities, regardless of whether participation requires the Participant to leave Camp premises and regardless of whether a separate fee was charged for the activity. In case of a medical or surgical emergency, I hereby give permission to any medical personnel selected by the Camp staff to administer treatment. I will assume full responsibility for any such action, including payment of all costs. It is understood that Indemnified Parties will provide no medical insurance for such treatment, and that the cost thereof will be at my expense. I hereby agree that any pictures or videos of Participant(s) may be used for Camp training, advertising, or promotion without any compensation to me or Participant. I acknowledge that some Camp activities may pose risks to Participant, including the risk of serious injury or death. By checking the box below I agree to all terms and conditions set forth above and give my consent for the listed participant(s) to participate in all camp activities on and off site. *

I agree

Submit

Scott Valley Funderblast Registration Form School Holiday 2019-2020

Scott Valley Funderblast Registration Form
School Holiday 2019-2020