iWalk the Eno 2014 - Eno River Association

iWalk the Eno 2014 - Eno River Association

iWalk the Eno 2014
Science & Nature Day Camp
Students in 3rd, 4th or 5th grade can apply
June 16 – 20 OR June 23-27
To#apply,#fill#out#and#return#the#following#by#March#31.#You#will#receive#a#letter#or#email#confirming#your#
child’s#acceptance#into#iWalk#the#Eno.#
#
Application#checklist:#
 Participant#Agreement#–#signed#by#student#&#parent/guardian#
 Camper#Code#of#Conduct#–#signed#by#student#&#parent/guardian#
 Frog#Hollow#Outdoors#Waiver#–#signed#by#parent/guardian#
 Health#&#Emergency#Contact#Information#Form#
 Include#a#check#for#$150#*#made#out#to#the#Eno#River#Association,#OR#$75#if#you#would#like#to#apply#for#
a#scholarship,#OR#
___#Check#here#if#you#are#enrolled#in#the#Federal#Food#Stamp#Program,#or#in#the#Free#or#Reduced#Lunch#
Program#at#school.#No#camp#fees#will#be#charged.#
#
Thank#you#for#applying#to#the#iWalk#the#Eno#Science#&#Nature#Day#Camp.#We#are#looking#forward#to#another#
great#week#on#the#Eno#River#in#June!#We#are#confident#that#your#child#will#receive#high#quality,#professional#
instruction#and#supervision#by#experienced#teaching#staff,#and#have#a#great#time#making#new#friends#and#
enjoying#the#Eno#River#each#day.##
#
HandsZon/feet#wet#activities#include:#
• Nature#and#science#investigations#
• Aquatic#explorations#and#wildlife#and#plant#studies#
• Creative#expression#through#music,#drama,#and#art#projects#
• Outdoor#recreation#such#as#hiking,#canoeing#and#outdoor#skills#
#
Thanks#to#major#funding#provided#by#the#Burroughs#Wellcome#Student#Science#Enrichment#Program,#each#
iWalk#camper#will#receive#a#backpack#with#supplies#to#use#during#the#camp,#including#a#reusable#water#bottle,#
an#Eno#bandana,#a#notebook#&#pencils,#and#an#iWalk#the#Eno#tZshirt.#These#supplies#will#be#theirs#to#keep#after#
the#camp#concludes!#Also#included:#canoe#rentals,#art#supplies,#and#busing#from#our#drop#off#locations#in#
Orange#County#to#the#Eno#River#State#Park#(see#Important#Information).
We#also#provide#a#balanced#healthy#lunch#and#snack#(morning#and#afternoon)#each#day.#Please#note#on#the#
enclosed#health#form#if#your#child#has#any#known#food#allergies,#as#well#as#any#other#health#or#medical#
conditions#(past#or#present)#that#will#help#our#staff#make#the#week#enjoyable#and#fun#for#your#child.
Mail#to:######Eno#River#Association#
iWalk#the#Eno#
#
4404#Guess#Road# #
Durham,#NC#27712
#
#
#
Email:#[email protected]#
Fax:#(919)#477Z0448#
Phone:#(919)#620Z9099,#ext.#204
Important Information
● The#camp#is#based#at#Few’s#Ford#in#the#Eno#River#State#Park#located#at#6101#Cole#Mill#Rd,#Durham.
● There#are#several#dropZoff#locations#in#Orange#County,#or#you#may#drop#your#child#off#directly#at#the#
Eno#River#State#Park.#Busing#information#and#directions#to#the#park#will#be#mailed#to#you#once#we#have#
received#your#camp#forms#and#application#fee#(if#applicable).
● Student#drop#off#is#between#8:00#–#8:30#am#each#day#in#Orange#County,#and#8:30Z9:00#in#Durham.
● Student#pick#up#is#between#4:00#–#4:30#pm#each#day,#except#on#Friday,#when#we#will#have#a#late#pickup#
following#our#camp#closing#celebration.#
On#Friday#June#20#or#June#27,#students#will#travel#by#bus#to#West#Point#on#the#Eno.##While#there,#we#will#meet#our#canoe#
guides#from#Frog#Hollow#Outdoors#and#spend#the#day#in#the#historic#West#Point#on#the#Eno#City#Park#in#Durham#learning#
basic#canoe#skills,#playing#games#and#touring#the#historic#buildings.##
We#will#return#to#Few’s#Ford#at#Eno#River#State#Park#for#our#Camp#Closing#Celebration.##We#invite#all#campers’#families#to#
join#us#for#this#celebration!##We#will#begin#at#3:30#and#end#at#approximately#4:15,#returning#to#our#pick#up#locations#by#
4:45.#Additional#information#about#the#celebration,#including#driving#directions,#will#be#sent#out#closer#to#the#date.#
7:50#–#8:20###Drop#Off#in#Orange#County
8:30Z8:45####Drop#Off#at#Eno#River#State#Park
9:00#
#Opening#Circle
9:15# #####Morning#Activities
11:45########Lunch#&#Games
1:00# #####Afternoon#Activities
3:15# #####Closing#Circle
3:30# #####Buses#Depart#Eno#River#State#Park#and#Pick#up#in#Durham#*
4–#4:30#Pick#up#in#Orange#County
Dates to Remember
Monday,#June#16#OR#June#23
st
● 1 #Day#of#iWalk#the#Eno#Camp
Friday,#June#20#OR#June#27
● Canoeing#at#West#Point#on#the#Eno#
● Closing#Celebration#at#Few’s#Ford#at#Eno#River#State#Park#(late#pick#up#day)
#
Late#Pick#Up#Charge:##$5.00#for#every#ten#minutes#after#4:30#at#bus#stops#in#Orange#County#and#after#4:00#for#
campers#picked#up#in#Durham#at#Eno#River#State#Park.
iWalk el Eno
Campamento)de)Ciencias)y)Naturaleza)durante)el)Día)
Para)el)16)al)20)o)23)al)27)de)Junio,)2014)
Para)estudiantes)entrando)el)4º,)5º,)y)6º)grados)
!
!
Gracias!por!venir!al!iWalk)el)Eno!Campamento)de)Ciencias)y)Naturaleza)de)Día.!¡Nosotros!
esperamos!con!impaciencia!otra!gran!semana!en!el!Eno!River!en!junio!!Con!la!mayoría!del!
personal!del!campamento!que!regresa!otra!vez!este!año,!estamos!seguros!que!su!hijo!recibirá!!
instrucción!y!supervisión!profesional!de!alta!calidad,!y!se!la!pasará!muy!bien!haciendo!nuevos!
amigos!y!disfrutando!el!Eno!River!todos!los!días.!!
!
Gracias!a!la!mayoría!de!fondos!proporcionados!por!Burroughs!Dando!la!Bienvenida!al!!
Programa!Estudiantil!de!Enriquecimiento!de!Ciencias,!cada!campista!iWalk!recibirá!una!
mochila!de!materiales!para!su!uso!durante!el!campamento,!incluyendo!una!botella!reusable!
de!agua,!una!pañoleta!Eno,!un!cuaderno!y!lápices,!y!una!camiseta!de!iWalk!el!Eno.!¡Estos!
materiales!se!los!podrán!quedar!una!vez!que!el!campamento!termine!!Esta!incluido!también:!
el!alquiler!de!canoa,!materiales!de!arte,!y!!transportación!desde!los!sitios!designados!en!el!
Condado!Orange!al!Parque!Estatal!Eno!River!(ver!información!importante).!
!
También!proporcionaremos!un!almuerzo!saludable!y!bocadillos!todos!los!días!(mañanas!y!
tardes).!!
)
Preguntas:!!!!Eno!River!Association!
!!!!iWalk!the!Eno! !!!!
!!!4404!Guess!Road!
!!!Durham,!NC!27712!
Email)[email protected]!
Fax)(919)!477W0448!
Telefono)(919)!620W9099,!x!204!
Información Importante Dej!
● El!campamento!esta!en!Few’s!Ford!en!el!Parque!Estatal!Eno!River!localizado!en!6101!
Cole!Mill!Rd,!Durham.!
● Hay!tres!lugares!asignados!en!el!Condado!Orange,!o!puede!dejar!a!su!hijo!directamente!
en!el!Parque!Estatal!Eno!River.!Se!le!enviara!por!correo!Información!para!registrarlo!en!
el!autobús!y!direcciones!al!parque!una!vez!que!recibamos!las!formas!del!campamento!y!
su!pago!(si!aplica).!
!
Haz)clic)en)"Like")en)nuestra)página)de)Facebook)para!informatición!y!foto!al!campamento.!
www.facebook.com/iwalktheeno!
Transportación Información!
7:50W8:20!!!Dejar!al!estudiante!en!Orange!County!
!
7:50W8:15!!!Stanback!Middle!School!
!
7:50W8:10!!!Gravelly!Hills!Middle!School!
!
8:00W8:15!!Cameron!Park!Elementary!
8:30W8:45!!!Dejar!al!estudiante!en!el!Parque!Estatal!Eno!River!!
!!9:00!
!!Abrir!el!Circulo!
!!9:15! !!!!!!!Actividades!de!la!Mañana!!
11:45! !!!!!!!Almuerzo!&!Juegos!!
!!1:00! !!!!!!!Actividades!de!la!Tarde!
!!3:15! !!!!!!!Cerrar!el!Círculo!
!!3:30!
Los!autobuses!salen!del!Parque!Estatal!Eno!River!!
!
4:00W4:30!!Cameron!Park!Elementary!
!
4:15W4:30!!Stanback!Middle!School!
!
4:15W4:30!!Gravelly!Hills!Middle!School!
!3:30!!!!!!!!!!!Recoger!al!estudiante!en!Durham!*!
4:00W4:30!!!Recoger!al!estudiante!en!el!Condado!Orange!
!
Lunes,)16)o)23)de)Junio)!
● 1 )Día)del)Campamento)iWalk)el)Eno)!
!
Viernes,)20)o)27)de)Junio)!
● Ir)en)canoa)en)West)Point)en)el)Eno)!
Celebrar)la)clausura)en)Few’s)Ford)(recoger)mas)tarde)!
st
●
!
El!viernes,!los!estudiantes!van!a!ir!en!autobús!a!West!Point!en!el!Eno.!Allí!vamos!a!encontrar!a!nuestros!
guías!de!canoa!de!Frog!Hollow!Outdoors!y!vamos!a!pasar!el!día!en!el!histórico!West!Point!en!el!Parque!
Eno!City!en!Durham!aprendiendo!el!arte!básico!de!ir!en!canoa,!jugando!juegos!y!recorriendo!los!
edificios!históricos.!!
Vamos!a!regresar!a!Few’s!Ford!para!Celebrar)la)Clausura)del)Campamento.!¡Invitamos!cordialmente!a!
todas!las!familias!de!los!campistas!a!unirse!a!nuestra!celebración!!Empezaremos!a!las!3:30!y!
terminaremos!aproximadamente!a!las!4:15,!regresando!a!los!lugares!asignados!para!recoger!a!las!4:45.!
Información!adicional!sobre!la!celebración,!incluyendo!las!direcciones!para!llegar,!las!enviaremos!
acercandose!la!fecha.!!
!
Recargo)por)recoger)tarde:!$5.00!por!cada!diez!minutos!después!de!las!4:30!en!las!paradas!del!
autobús!en!el!Condado!de!Orange!y!después!de!las!4:00!para!campistas!en!Durham!en!el!Parque!
Estatal!Eno!River.!
!
!
!
!
Student!Information!
Application!for:!
 June!16H20,!2014!OR!!
 June!23H27,!2014!OR!!
 Either!week!is!fine
iWalk!the!Eno!
Participant!Agreement!Form!
Name________________________________________________________________________________________&
Date&of&Birth____/____/_____&& &
Age_____&&
&
Gender:&&
&Male&&
&Female&
School&____________________________&&&&&&&Teacher&__________________&&&&&&&&Grade&(2013A2014)_________&
TAShirt&(one&free/student):&Circle&size&
Youth&Sizes:&&S&&&M&&&L&&& OR&&
Adult&Sizes:&&&XS&&&S&&&M&&&L&&&XL&&&
Address_______________________________________________________________________&
Street&
&
&
&
&City&&
&
&
State&&
&
ZIP&
Home&Phone&(_____)&____________________________________&
Email_________________________________________________________________________&
Parent!or!Guardian!Information!
Father&______________________________&&
&
&
Mother&______________________________&
Day&Phone&_________________&&
&
&
&
Day&Phone_____________________&
Night&Phone&_________________&&
&
&
&
Night&Phone____________________&
Medical!Information!
Insurance!Company______________________________!!
Phone!#_________________________________&
Policy!#!________________________________________!
Group!#_________________________________!
Releases!and!Signatures!
• We&understand&that&iWalk&the&Eno&includes&rigorous&activities&and&are&meant&for&students&who&
have&an&interest&in&science,&outdoor&activities,&and&environmental&protection.&
• We&understand&that&the&student’s&parent/guardian&must&assume&responsibility&for&medical&
examinations,&transportation&to&and&from&the&site,&and&payment&for&any&medical&expenses&incurred&
by&the&student&during&the&program.&
• We&agree&to&adhere&to&iWalk&the&Eno&rules&and&regulations&concerning&students’&behaviors&and&
responsibilities.&We&understand&that&the&iWalk&the&Eno&Administrators&and&Educators&have&the&
right&to&dismiss&any&student&whose&behavior&is&not&consistent&with&the&goals&and&standards&of&
iWalk&the&Eno.&
• We&agree&that&photographs&or&videos&of&the&student&taken&during&the&program,&data&collected&by&
the&student&during&the&program,&and&similar&items&may&be&used&by&iWalk&the&Eno&in&reports&and&
public&information&materials.&We&also&agree&that&students’&information&may&be&used&in&press&
releases,&student&directories,&and&similar&publications.&
• We&have&read&and&understood&the&above&Releases&and&attest&that&the&information&in&this&
application&is&true&and&accurate.&
!
Student!Signature!
!
!
Parent/Guardian!Signature!
!
!
Date! !
!
Date! !
Para&fechas:&
 16J20&de&Junio,&2014&
 23J27&de&Junio,&2014&
 Cualquiera&de&las&dos&
semanas
iWalk&el&Eno&
&
Contrato&de&Participacion&
Información&del&Estudiante&
Nombre______________________________________________________________________________________(
Fecha(de(Nacimiento____/____/_____(( (
Edad_____((
Sexo:(( (Masculino(( (Femenino(
Escuela(_________________________(Maestro(__________________(Grado((2013@2014)(_________________((((((((((((((((
Camiseta(((una(gratis/estudiante):(¿Cual(talla?( Talla(Juvenil:((S((M(((L(
((O(
Talla(de(Adulto:(((XS(((S(((M(((L((((XL(
Dirección_______________________________________________________________________________(
Calle(
(
(
(
(Cuidad(
(
(
Estado(
(
Código(postal(
Teléfono(de(casa((_____)(____________________________________(
Correo(Electrónico_________________________________________________________________________(
Información&del&Padre&o&Guardián&&
Padre(______________________________((
(
(
Madre(_________________________________(
Teléfono((de(día______________________(
(
(
Teléfono(de(día___________________________(
Teléfono(de(tarde(____________________(
(
(
Teléfono(de(tarde_________________________(
Compañía&de&Seguros_________________________________& Teléfono&________________________________(
Num&de&Póliza&________________________________________&Num&del&Grupo&___________________________&
Notas&y&Firmas&
• Entendemos(que(iWalk(el(Eno(incluye(actividades(rigurosas(y(es(para(los(estudiantes(que(tienen(
interés(en(ciencias,(actividades(al(aire(libre,(y(en(la(protección(del(medio(ambiente.(
• Entendemos(que(los((padres/guardianes(del(estudiante(deben(de(asumir(la(responsabilidad(de(los(
exámenes(médicos,(el(transporte(de(ida(y(vuelta(al(sitio(designado,(y(el(pago(de(gastos(médicos(
incurridos(por(el(estudiante(durante(el(programa.(
• Estamos(de(acuerdo(en(adherirnos(a(las(normas(y(reglamentos(de(comportamiento(y(
responsabilidades(de(los(estudiantes(de(iWalk(el(Eno.(Entendemos(que(los(Instructores(y(
Administradores(de(iWalk(el((Eno(tienen(el(derecho(de(despedir(a(cualquier(estudiante(cuyo(
comportamiento(no(es(consistente(con(las(normas(y(objetivos(del((iWalk(el(Eno.(
• Estamos(de(acuerdo(que(las(fotos(o(videos(que(se(toman(del(estudiante(durante(el(programa,(los(
datos(que(recoge(el(estudiante(durante(el(programa,(y(objetos(similares(pueden(ser(utilizados(por((
iWalk(el(Eno(en(reportes(y(materiales(de(información(pública.(También,(estamos(de(acuerdo(que(la(
información(de(los(estudiantes(puede(ser(utilizada(por(la(prensa,(directorios(de(estudiantes,(y(
publicaciones(similares.(
• Hemos(leído(y(entendido(las(Notas(anteriores(y(certificamos(que(la(información(en(esta(solicitud(es(
correcta(y(verdadera.(&
Firma&del&Estudiante&
&
Fecha& &
!
!
Firma&del&Padre/Guardián&&
&
Fecha& &
&
iWalk&the&Eno&
&
Camper&Code&of&Conduct&
&
!
!
I!understand!that!my!attitude!and!behavior!are!critical!to!my!success,!and!to!the!success!
of!camp!this!summer.!!Therefore,!for!the!good!of!all,!I!agree!to!abide!by!the!following:!
!
1. I!will!try!to!be!sensitive!to!the!needs!of!each!camper!by!performing!my!
assigned!duties,!including!but!not!limited!to:!participating!in!all!camp!
activities,!cleanup,!etc.!
2. I!will!respect!the!places!and!the!people!with!whom!I!come!in!contact.!
3. I!understand!that!the!use!of!alcohol,!tobacco,!profane!and/or!
threatening!language,!or!drugs!will!not!be!tolerated,!and!that!usage!
during!camp!will!result!in!expulsion!from!my!camp!program.!
4. I!will!be!responsible!for!my!personal!belongings!and!equipment!and!
will!not!hold!iWalk!the!Eno!or!any!other!outsider!responsible!for!the!
loss!or!damage!due!to!my!negligence!or!neglect.!!!
5. I!will!treat!equipment!provided!by!iWalk!the!Eno!or!any!other!person!
with!care.!
6. I!will!use!safety!equipment!furnished!by!iWalk!the!Eno!for!my!own!
safety.!
7. I!will!treat!other!campers!and!staff!with!respect!and!courtesy.!!!
8. I!understand!that!if!I!can!not!abide!by!the!guidelines!listed!above,!the!
Staff!Leaders!will!notify!my!parents/guardians,!and!I!will!be!sent!home.!!
&
&
&
Camper&Signature&
&
Date& &
!
I!have!read,!understand!and!agree!with!the!above!responsibilities!of!my!child!while!participating!in!the!
iWalk!the!Eno!Summer!Camp.!
!
Parent/Guardian&Signature& &
Date& &
!
!
iWalk!el!Eno!!
!
Camper!Código!de!Conducta!!
!
Entiendo!que!mi!actitud!y!mi!comportamiento!son!fundamentales!para!tener!éxito,!y!para!el!
éxito!de!este!campamento!de!verano.!!Por!lo!tanto,!para!el!bien!de!todos,!me!comprometo!a!
cumplir!con!lo!siguiente:!
!
1. Voy!a!tratar!de!ser!sensible!a!las!necesidades!de!cada!campista!llevando!a!
cabo!mis!deberes!asignados,!incluyendo!pero!no!es!limitado!a:!participar!en!
las!actividades!del!campamento,!en!la!limpieza,!etc.!
2. Voy!a!respetar!los!lugares!y!a!la!gente!con!quien!tenga!contacto.!!
3. Entiendo!que!el!uso!de!alcohol,!tabaco,!drogas,!o!lenguaje!profano!o!
amenazante!no!será!tolerado,!y!que!el!uso!durante!el!campamento!será!
motivo!de!expulsión!del!programa!de!campamento!de!verano.!
4. Seré!responsable!por!mi!equipo!y!cosas!personales!y!no!haré!!al!iWalk!el!Eno!
o!ninguna!!otra!persona!ajena!responsable!por!daños!o!pérdidas!debido!a!mi!
descuido!o!negligencia.!
5. Voy!a!tratar!con!cuidado!el!equipo!proporcionado!por!el!iWalk!el!Eno!o!
cualquier!otra!persona.!
6. Voy!a!usar!el!equipo!de!seguridad!proporcionado!por!el!iWalk!el!Eno!para!mi!
propia!seguridad.!
7. Voy!a!tratar!al!personal!y!a!los!otros!campistas!con!respecto!y!cortesía.!
8. Entiendo!que!si!no!puedo!cumplir!con!los!lineamientos!mencionados,!los!
líderes!del!personal!van!a!notificar!a!mis!padres/guardianes,!y!me!van!a!
enviar!a!casa.!!
!
!
Firma!del!Estudiante!!
!
Fecha! !
!
He!leído,!entendido!y!estoy!de!acuerdo!con!las!responsabilidades!de!mi!hijo!durante!su!participación!en!el!
Campamento!de!Verano!iWalk!el!Eno.!!
!
Firma!del!Padre/Guardián!!
!
Fecha! !
HEALTH & EMERGENCY Card
Student’s Name: (last, first, middle)
___________________________________________________
Birth date: ____________ Sex:
M
F Race:___________
Home Phone:__(_____)_______________________________
MOTHER’S Name:___________________________________
Work Phone:___(_____)______________________________
Emergency Contact
List 2 nearby adults who will take care of your child if you
cannot be reached right away.
Cell Phone:____(_____)______________________________
NAME:______________________________________________
E-mail:_____________________________________________
Relationship:_________________________________________
FATHER’S Name:____________________________________
Daytime Phone Number: _(_____)_______________________
Work Phone: __(_____)_______________________________
NAME:______________________________________________
Cell Phone: ___(_____)_______________________________
Relationship:________________________________________
E-mail:_____________________________________________
Daytime Phone Number:_(_____)________________________
Student lives with:___________________________________
Street Address (not P.O. Box):
Doctor:________________ Phone: (_____)________________
___________________________________________________
Mailing Address (if different from above):
Dentist:________________ Phone: (_____)________________
___________________________________________________
City, State, & Zip Code:
Hospital Preference (cannot guarantee):___________________
___________________________________________________
CONFIDENTIAL INFORMATION
ALLERGIES - write the specific allergy below:
MEDICATIONS – list below:
Food
Epi Pen
1.
Insects
Epi Pen
2.
Medication allergies
Takes at home?
Other allergies
Emergency Medications?
At School?
Both?
Circle any medical conditions that your child has:
ADD/ADHD
Diabetes
Orthopedic Problem
Vision Problems
Arthritis
Hearing Problems
Psychiatric Disorder
Other Conditions:
Asthma
Heart Problems
Seizures
Bleeding Disorder
Migraines
Sickle Cell
Explain (date of last episode, etc.)
Has student been hospitalized in the past year? Yes
Explain
In the case of a serious accident or illness, camp staff will contact Orange or Durham County EMS (emergency medical services). I
understand that my child’s medical information will be shared as necessary with camp staff and emergency personnel in order to
provide appropriate health care services.
Parent/Guardian Signature
Date
SALUD
Nombre del Estudiante: ( pe ido, primero,
EMERGENCIA
)
___________________________________________________
Fecha de Nacimiento: __________ Sexo:
Tel de
M
F Raza:___________
: (_____)______________________________
Nombre de l MADRE:_________________
Tel del Trab
(_____)_______________________ ______
Mobil: (_____)_____________
___________________
Nombre:______________
Correo Electronico:___________________________________
:_________________________________________
Nombre del PADRE:_________________
Tel d
Tel del Trabajo: __(_____)________________________
Nombre:______________________________________________
Mobil: ___(_____)___________________________
Dia:(_____)_______________________
:________________________________________
Correo Electronico:__________________________________
Tel d
Dia:(_____)_____________________
El Estudiante vive con:____________________
Dire cion (no
):
Doctor:________________ Tel : (_____)______________
___________________________________________________
Direccion
(si es diferente
):
Dentista:________________ Tel : (_____)________________
___________________________________________________
C dad, Estado, Codigo
:
Hospital
(no e garantiza):___________________
___________________________________________________
C
ALERGIAS -
la alergia specifica:
EDICAMENTOS–
Comida
Epi Pen
1.
Insectos
Epi Pen
2.
Ale gia
Medicamentos
Toma
abajo:
casa?
a escuela?
Los dos?
Medicamentos de Emergencia?
Otras Alergias
Circ l
condicion medica que tenga tu hijo:
ADD/ADHD
Diabet s
Problema Ortopedico
Problemas de l Vis
Artritis
Problemas de
Trastorno Psiquiatrico
Otras Condiciones:
Asma
Problemas de Corazon
Convulsiones
Trastorno de la coagulacion
Migranas
Hoz de la Celula
Explicar (fecha del ultim
, etc.)
El estudiante ha sido hospitalizado
*Nota: El personal
medica
cas
Explicar
el ultimo ano? Si
NO va administrar NINGUN medica
a los estudiantes (ya sea receta
supervis
stud nt s
n a
zipl
n m e
INCLU E a not
supervision.
accident o
,
informa ion
pro
camp
o sin receta medica). Nuestro
medica
(
inhal
permiso
contact
camp
servic s
Firma de Padre/Guardian
.
Fecha
March 2011
asma).
WAIVER AND RELEASE OF LIABILITY
FROG HOLLOW
______________________________________________
Participantís Name (Please Print)
______________________________________________
Address
IMPORTANT. READ CAREFULLY. This document affects your legal rights. It must be signed by you the
ìParticipantî, whether you are an adult or minor, if you are renting or otherwise using equipment or participating in
activities offered by Frog Hollow LLC. It must be signed also by your parent or guardian if you are a minor
Participant. The parent or guardian agrees to these terms individually and on behalf of the minor. Only a parent or
legally appointed guardian may sign for a minor Participant. References to ìIî or ìweî include all who sign below
unless otherwise clearly indicated.
PARTICIPANT AGREEMENT
(Including Acknowledgement and Assumption of Risks,
Agreements of release and Indemnity, and Additional Provisions)
In consideration of the opportunity to rent or otherwise use certain equipment and/or participate in activities offered by
Provider, Participant (adult or minor), and the parent or guardian of a minor Participant, understand, acknowledge and
agree as follows:
[PART II] Activities, Hazards and Risks
The services of the Provider may include renting equipment and providing trips (including guided trips) by canoe or
kayak (referred to, collectively, as watercraft). Activities, scheduled and unscheduled, associated with these services
may include, in addition to travel by water, swimming, wading, hiking, climbing on rocks and slopes, camping,
portaging (carrying the watercraft between water travel sites) and travel to and from the activities.
The hazards and risks (together referred to as ìrisksî) of the use of watercraft include the following: entering, exiting,
and operating watercraft; water which may be fast, deep, cold, and subject to rapid change; objects which may be
encountered in and out of the water, and which may not be obvious, including debris, trees, rocks, boulders, dams,
bridges, and other hazards; the watercraft may overturn, swamp and sink and occupants may become separated from
the craft; feet and other parts of the body may become entrapped in or under rocks and other objects; participants may
strike or be struck by objects, other watercraft, and other persons, in and outside of the watercraft. Risks of other
activities include those associated with camping, hiking and moving on and over terrain, including the shoreline, the
premises of Provider and others, and elsewhere, which may be unstable, steep and slippery and where rocks, trees, and
other objects may fall, and man-made and natural structures may fail; animals, including poisonous reptiles, poisonous
insects, and poisonous plants may cause harm; swimming in unfamiliar surroundings may cause entrapment, injury
from slips and falls and drowning. Other risks include errors in judgment of Providerís staff and other participants,
including the improper assessment of capabilities and conditions pertaining to the activities; certain activities may be
instructional, and designed to extend the skills of participants; equipment may be misused or may fail because of
manufacturing defects or otherwise; collisions may occur while traveling by vehicle to and from the activities; the
activities are subject to the unpredictable forces of nature, including exposure to the sun, cold, wind, hail, lightning,
flash floods and other such phenomena; activities may take place in remote places, significantly delaying emergency
medical care and evacuation.
Participant, and the parent or guardian of a minor participant, acknowledge and understand that the description of
activities and risks above is not complete and that all activities, whether or not described, may be dangerous and may
include risks which are inherent and cannot be reasonably avoided without changing the nature of the activity.
Participation in the activities can cause bites, stings, allergic reactions, overexertion, heat stroke, hypothermia, illness
due to contaminated water, burns, cuts, bruises, strains, broken bones, and other injuries and illnesses. Property loss,
and serious injury and death, including by falling and drowning, are possible.
Client, and the parent or guardian of a minor Participant, accepts full responsibility for determining Participantís
medical, physical or other qualifications or suitability for participating in the activities. Provider is not responsible for
water conditions, routes, camp sites, or other activities of renters of its equipment. Alcohol will, and other substances
may, impair judgment and reduce a participantís ability to effectively manage the risks of water travel, camping, and
land activities; participants should inspect unfamiliar rapids and other hazards before attempting to pass through or over
them; participants should always wear a fastened life jacket (personal flotation device); participants should wear
footwear which will provide protection from sharp objects, and which will minimize the risk of foot entrapment.
Failure to adhere to these and other safety precautions may result in serious injury or death.
[PART III] Acknowledgement and Assumption of Risks
I, the Participant (adult or minor) and the parent or guardian of a minor Participant, understand the nature of the
services of Provider and other activities, which may occur, and their risks. I acknowledge and expressly assume all
risks of the activities, whether or not described above, known or unknown, and inherent or otherwise. I take full
responsibility for any injury or loss, including death, which I, or a minor child for whom I sign, may suffer, arising in
whole or part out of such activities.
[PART IV] Agreement of Release and Indemnification, and Additional Provisions
If I am an adult participant, or the parent or guardian of a minor Participant, I agree, for myself and on behalf of the
minor Participant for whom I am signing, as follows:
I release Provider, its employees, contractors, volunteers, directors and owners (ìReleased Partiesî) from any and all
claims of injury or loss which I, or the minor child for whom I sign, may suffer, arising out of or in any way related to
my, or the childís, enrollment in or participation in the activities of Provider or the use of its equipment. Neither I, the
minor child, nor anyone acting on our behalf, will bring suit or otherwise assert any such claims against a Released
Party.
I will indemnify (that is, defend and satisfy by payment or reimbursement, including costs and attorneysí fees) each
Released Party from any claim of liability, including one brought by or for a minor child whom I sign, a co-participant
in any of the activities of Provider, a rescuer, a member of my, or the minor childís, family, or any one else, asserting a
loss arising out of or in any way related to my, or the childís, enrollment in or participation in the activities of Provider
or the use of its equipment.
The agreements of this release and indemnification above include claims arising in whole or in part from negligent (but
not grossly negligent, reckless or intentionally wrong) acts or omissions of Released Parties or any of them, and all
other claims, including for personal injury, wrongful death, property damage, products liability (including strict
liability), breach of contract or warranty, or otherwise. The agreements are intended to be enforced to the fullest extent
allowed by law, and to be binding on me as Participant and on me as parent or guardian of a minor Participant,
individually and on behalf of the minor for whom I sign.
[PART V] Additional Provisions
I authorize Provider to provide or obtain for me, or the minor child for whom I sign, such medical care as it considers
necessary and appropriate, and I agree to pay all costs associated with such care and related transportation. Any
dispute between Provider and me or the minor child for whom I sign will be governed by the substantive laws of the
State of North Carolina (not including laws which might apply the laws of another jurisdiction), and any mediation or
suit shall take place only in that State, in the County of Durham. If the dispute cannot be resolved by mutual
agreement, I agree to submit it to a mediator recognized by the Courts of that State and County. I agree to pay all costs
and attorneysí fees incurred by Provider in defending a claim or suit brought by me or by or on behalf of the minor for
whom I sign, if the claim or suit is withdrawn or to the extent a court or mediator determines that Provider is not
responsible for the claimed injury or loss.
[PART VI]
This agreement is entered into voluntarily, and after careful consideration. Its terms cannot be amended except in
writing. I understand that it is binding, to the fullest extent allowed by law, upon all persons signing below, our
respective heirs, executors, administrators, wards, minor children (whether or not they are Clients) and other family
members. If any part of this agreement is found by a Court or other appropriate authority to be invalid, the remainder
of the agreement nevertheless shall be in full force and effect.
________________________________
Participant (adult or minor)
Date: ___________________________
________________________________
Parent or Guardian
Date: ___________________________