CAMP COOL Health History Form to Be Completed by Athlete’S Parent Or Guardian

DATE:______

CAMP COOL Health History Form To be completed by athlete’s parent or guardian. Camp Cool respects your right to privacy, therefore, all information provided will be strictly confidential.

Please print clearly or type. 1. Camper’s Name:______Gender: __ F __ M Age:______Birthdate: ______Disability: ______Parent/Guardian:______Address: ______City:______Zip:______Home Phone: ______Work Phone:______Email:______Fax Number: ______

2. EMERGENCY CONTACT Name: ______Phone: ______Address: ______City: ______Zip: ______Relationship to Camper: ______

3. Describe in Detail Camper’s Disability: ______

4. Describe Any Significant Illnesses and/or Operations of the Camper and Indicate Month and Year: ______

5. Describe Any Range-of-Motion Limitation: ______

6. Specify Camper’s Assistive Devices (i.e. wheelchair, crutches, walker, etc.):______

7. Is the Camper Prone to Seizures: YES NO If Yes, Controlled By medication? YES NO Type: ______Frequency: ______Date of Last Seizure: ______Symptoms Camper Experiences Prior To and After A Seizure: ______

9. List Allergies and Nature of Reaction: ______

10. Explain In Detail Camper’s Bowel/Bladder Program: ______

11. Explain In Detail Camper’s Hygienic Needs: ______

12. List Any of the Camper’s Adaptive Sports Equipment That He/She Will Be Bringing To Camp:______

13. Special Instructions or Additional Information: ______

14. List Any Wheelchair Sport/Leisure Interests of the Camper: ______

15. Camper’s Medical Insurance Provider: ______Insurance Carrier: ______Policy #: ______Physician’s Name: ______Phone: ______***Please attach a photocopy of camper’s medical card.

If the camper needs to be taken to the hospital, he/she will be taken to an appropriate medical facility depending on the severity of the injury.

I, ______, give permission for my son/daughter, ______to participate in Camp Cool activities. Should it be necessary for the athlete to seek emergency medical attention, I hereby give Camp Cool employees permission to use their best judgment to obtain needed medical services. I authorize the emergency physician/hospital to render emergency treatment to the client. I understand that the medical costs incurred by the athlete are the responsibility of the athlete/parents/guardians.

All athletes/parents/guardians participating in Camp Cool activities are deemed to have waived all claims against Camp Cool, its owner, employees, or volunteers for injury, accident, illness, or death occurring during any Camp Cool excursion or activity.

The recreation activities that athletes will be participating in are: snow skiing; curling; sled hockey; and aerobic conditioning. Campers/parents/guardians hereby acknowledge the events are recreational activities that are inherently dangerous and can result in injury. Nevertheless the athletes/parents/guardians hereby waive any and all claims against Camp Cool, California State University Sacramento, City of Sacramento, Access Leisure, Disabled Sports USA, and any employees, volunteers, and agents that may arise out of injuries incurred while an athlete is participating in any of the recreational activities described above.

______Signature of parent/guardian Date

Talent Release and Photo Consent

I, ______, give my permission to have my son/daughter, ______to be photographed and videotaped for Camp Cool promotional and fund-raising purposes.

______Signature of parent/guardian Date MEDICATION AUTHORIZATION FORM

MEDICATION SCHEDULE INFORMATION

Prescription and over the counter medications should be in clearly marked containers listing name of person receiving medication, name of medication, dosage and time it is to be dispensed. Doctor’s name should also be listed on any prescription medications. Please include directions regarding how to administer medications, side affects or restrictions associated with the medication.

Name of Medication Dosage Time Special Information

______

Signature______Date______

Parent_____ Guardian_____ Caregiver______Conservator_____

med auth Health Examination Form for Camp COOL must be completed by the parent/guardian AND PHYSICIAN and must be received by the Camp Registrar before start of the camp.

Name: ______Age: _____

Disability (be specific): ______

______

Is Camper Covered By Medical Insurance? [ ]Yes [ ]No Name of Insurance Company: ______Insurance Plan Number: ______**Please attach a photocopy of current Medical Card.

Health History (check and give appropriate dates if known): ___Asthma: ______Arthritis: ______Chicken Pox: ______Diabetes: ______

Other: ______

Medication: IS CAMPER ON MEDICATION? [ ]Yes [ ]No

Name(s) of medications: ______

______**Camper is required to bring ample supply of all medications, with prescriptions to camp. All medicines MUST be prescribed and in their original containers (including all vitamins and herbs) and will be administered according to the doctor’s written instructions.

Diagnosis of Disabling Condition(s): ______

Height: _____ Weight: ______Blood Pressure: ______C.B.C. ______Urinalysis: ______

List any remarkable conditions: ENT: ______Extremities: ______Heart: ______Posture (spine): ______Lungs: ______Skin: ______Abdomen: ______Allergies: ______

Special Diet: ______

Are there any other recommendations or special instructions regarding Camper’s activity limitations? ______

I have examined ______and reviewed his/her Health History. In my opinion this Camper is physically able to engage in camp activities, except as noted. I have attached prescriptions for the Camper as needed.

EXAMING PHYSICIAN: ______(Please type or clearly print name)

Address: ______City: ______St:_____ Zip: ______

Telephone Number: ______

Signature of Examining Physician: ______Date: ______

THIS FORM MUST BE SIGNED AND DATED BY PHYSICIAN (within one year of camp start date) AND RECEIVED BY CAMP COOL PRIOR TO START DATE.

Medicals are good for two years, so if you have a current medical form on-file from 2011 that has not changed regarding medications and or operations, please let us know.

Mail To: City of Sacramento Parks and Recreation Access Leisure-Jenny Yarrow 5735 47th Avenue Sacramento, CA 95824

Tel: (916) 808-6017

Fax: (916) 808-3559

CAMP C.O.O.L. CAMPERS CODE OF CONDUCT

1. Camp C.O.O.L. campers shall conduct themselves in conformity to City of Sacramento, Access Leisure policies and procedures and with the traditional etiquette of residential camps. This includes, but is not limited to: bringing credit and honor to yourself, your peers, your counselors, volunteers, and the Camp C.O.O.L. Program.

2. All campers will display proper respect and behavior toward peers, counselors, administrators, volunteers, and the public.

3. All campers will practice appropriate conduct such as but not limited to:

• Campers will try their best to participate in all camp activities. • Campers must strive to be as independent as possible. • Maintain a positive attitude. • Treat fellow campers and staff as you would like them to treat you. • Campers will treat equipment and lodging facility with respect. • Camper will follow all rules set forth by transportation personnel both prior to, during trip, and when unloading. • Know and follow the rules of the activities/events you are participating in. • Campers will not use or consume alcohol, tobacco or illegal drugs. • Campers will not purposefully engage in unsafe activities.

Action to be taken if a Camper issue arises as a result of not complying with code of conduct:

1. Camp Director and Camp Program Coordinator will confer to determine the behavior issue and discuss a reasonable solution prior to dismissal. 2. Camp Director and/or Camp Program Coordinator will then discuss the issue with Camper and give the camper an opportunity to rectify the problem. 3. If the behavior persists, the camper will be informed that he or she is to be dismissed from camp. Exception: If the behavior results in an intentional injury to self, other campers, staff or volunteers, no counseling may occur and the camper may be asked to leave without the opportunity to amend his or her behavior.

The administrators of Camp C.O.O.L. are responsible for enforcement of the Code of Conduct.

I, ______understand that if I choose to engage in behaviors or unsafe activities that create a potential hazard to the emotional or physical safety of other campers, staff, and/or volunteers; or am disruptive to the operation of camp, staff may ask me to depart camp.

______Signature Date

______Parent Signature if Camper Under 18 Date

Disabled Sports USA, Far West 2016 Participant Information

Name: (Participant) ______Daytime Phone: ______Email: ______Cell Phone: ______Address: ______City: ______State: ______Zip: ______County: ______Occupation: ______Military Rank & Branch:______Emergency Contact: ______Relation: ______Cell Phone: ______Emergency Contact: ______Relation: ______Cell Phone: ______If Participant is a Minor or Dependent Adult:

Guardian: ______Relation: ______Occupation: ______Address: ______City: ______State: ______Zip: ______Email: ______Primary Phone: ______( H W C )

PARTICIPANT DISABILITY: ______How long? ______Date of Birth: ______Height: ______Weight: ______Male/Female: ______Ethnicity: ______For participants with Down Syndrome: We require an examination by a physician for Atlantoaxial Instability

before participating. Physician Results/Findings: ______

Please give explanations in space provided below.

“Does Participant…” 1. Have seizures?_____ Type?______Frequency?______Date of last seizure?______Seizure management (e.g. Meds, etc.):______2. Have allergies (e.g. latex, bees, foods, drugs)? ______3. Take medications we should be aware of? ______4. Need precautions taken for any injuries or surgeries in the past 6 months? ______5. Have other hidden medical conditions? ______6. Have sensitivity to cold, heat or sun? ______Fatigue easily? ______7. Have a respiratory condition? ______Have a cardiovascular condition? ______8. Use manual wheelchair? ______What % of time? ______Power wheelchair? ______What % of time? ______9. Need assistance operating wheelchair? ______Transferring to or from wheelchair? ______10. Walk? ______What % of time? ______With what kind of aid? ______11. Wear any braces? ______Type of brace: ______12. Have rods stabilizing any part of spine?______How long: ______13. Have any pressure sores/significant bruises? ______14. Describe communication abilities. ______15. Describe vision and hearing abilities. ______16. Describe behavioral tendencies.______17. Describe cognitive level.______18. Describe arm strength______grip strength ______feeling ______range of motion______19. Describe leg strength______balance______feeling ______range of motion______20. How long can you be independent from medications, oxygen, etc. that you cannot have on your person? ______OVER Page 1 of 2

How did you hear about us? ______

Please read and initial that you understand these program requirements:

ALL SPORTS Health and Safety: ♦ If you think participating in the Disabled Sports programs below may cause you pain or injury, please consult your doctor and provide us with a doctor’s written release prior to participating. Initial _____ Personal Care: ♦ If help is needed with bladder or bowel routine, feeding tube, or administering prescription medications attendant or family member will be present to assist. Initial _____

SNOW SPORTS ♦ Sit-down skiers weight limit is 185 lbs. Exceptions will be considered for skiers who are fully independent transferring from wheelchair to ski and loading and unloading chairlift. Initial _____ ♦ While strapped in a sit-down ski you will unload the chairlift, with assistance, by dropping down as much as 2 feet onto the unloading ramp. In this unloading process, your hips and back must be able to sustain this jarring. Initial _____

SUMMER SPORTS Water skiing: ♦ Wheelchair users seat cushion width may not be greater than 18”. Initial _____ ♦ You are able to turn face-up from a face-down floating position in the water, while wearing a life vest. Initial _____ ♦ Skiers will be towed behind or alongside a motorboat at speeds up to 25 mph. Should you fall, your body must be able to sustain the impact of hitting the water at these speeds. Initial _____ ♦ If help is needed with bladder or bowel routine, feeding tube, or administering prescription medications attendant or family member will be present to assist. Initial _____

4-wheel drive trips: ♦ Weight limit is 185 lbs. for wheelchair users. Exceptions will be considered if you are fully independent and strong enough to transfer down and up about 12”. Initial _____ ♦ You will experience a bouncing motion from the vehicle driving over rough terrain. Initial_____ ♦ Wheelchair users may need to be carried over inaccessible terrain. Wheelchair accessible portable toilet with privacy tent will be available. This toilet does not have handrails. Initial____ ♦ If help is needed with bladder or bowel routine, feeding tube, or administering prescription medications attendant or family member will be present to assist. Initial _____

Sierra Summer Sports or Tahoe Paddle Sports: ♦ Weight limit is 185 lbs. for wheelchair users. Exceptions will be considered if you are fully independent and strong enough to transfer down and up about 12”. Initial _____ ♦ You are able to turn face-up from a face-down floating position in the water, while wearing a life vest. Initial _____ ♦ If help is needed with bladder or bowel routine, feeding tube, or administering prescription medications attendant or family member will be present to assist. Initial _____

In signing below, I verify that the information on pages 1 and 2 is current and accurate. I understand this information is confidential and will be used only by Disabled Sports USA Far West.

______Printed Name Signature Date

Page 2 of 2 Disabled Sports USA Waiver & Release of Liability, and Media Release Agreement Disabled Sports USA, and its affiliated Chapters (“Released Parties”) are non-commercial, not for profit activity providers. The purpose of this agreement is to exempt, waive and relieve Released Parties from any and all liability for wrongful death, personal injury, and property damage, including, but not limited to, liability arising from the negligence of Released Parties. “Released Parties” include Disabled Sports USA , Disabled Sports USA Far West and their representatives, administrators, directors, agents, coaches, employees, and volunteers; other participants, sponsoring agencies, sponsors, and advertisers; and, if applicable, the owners, operators, and lessors of premises on which the activities or events take place. In consideration of the undersigned Participant being allowed to participate in any way in Disabled Sports USA and/or Disabled Sports USA Far West related events and activities, the Undersigned (“Undersigned” means the Participant or the Participant’s parent, legal guardian, or legal representative when the Participant is under the age of 18 or legally incapacitated) agrees and acknowledges as follows: 1. Risks of Activity. Participant will be taking part in activities that and expenses whether or not in litigation, arising out of, or related to, can be hazardous and involve the risk of physical injury and/or death. Participant’s participation in the activities. The activities are inherently dangerous and Undersigned fully realizes 3. Helmet Use. Undersigned agrees that Participant shall use a the dangers of participating in the activities. The dangers and risks of helmet when participating in the following activities: Alpine skiing, the activities include, but are not limited to the condition of the cycling, equestrian, ice hockey, outdoor rock climbing, snowboarding, premises and equipment, and the acts, omissions, representations, white water kayaking, white water river rafting, and any other activity carelessness, and negligence of the Released Parties. Recognizing the when directed by Released Parties. Undersigned understands that a risks and dangers, the Undersigned voluntarily chooses for Participant helmet is in no way a guarantee of safety and that no helmet can to participate in the activities and expressly assumes all risks and protect the wearer against all foreseeable impacts to the head, and dangers of the participation in the activity, whether or not described that the activities can expose the Participant to forces that exceed the above, known or unknown, inherent, or otherwise. limits of protection provided by a helmet. Undersigned agrees to 2. Release and Indemnification. Undersigned (a) unconditionally assume full responsibility for complying with this paragraph and that releases, forever discharges, and agrees not to sue the Released Released Parties shall not be liable for any injury or damages resulting Parties for any claims or causes of action for any liability or loss of any from Participant’s failure to use a helmet. nature, including personal injury, death, and property damage, arising 4. Miscellaneous. Undersigned agrees (a) Participant will not out of or relating to Participant’s participation in the activities, engage in any activities prohibited by any applicable laws, statutes, including, but not limited to claims of negligence, breach of warranty, regulations and ordinances; (b) this agreement shall be governed by and/or breach of contract the Undersigned may or will have against the laws of the State of CA and the exclusive jurisdiction and venue for the Released Parties; and (b) agrees to indemnify, defend, and hold any claim shall be located in the state courts located in Placer County, harmless the Released Parties from and against any liability or damage CA; and (c) this agreement shall be binding upon the subrogors, of any kind and from any suits, claims or demands, including legal fees distributors, heirs, next of kin, executors, and personal representatives of the Undersigned. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT I AM RELEASING LEGAL RIGHTS THAT OTHERWISE MAY EXIST.

Participant’s Signature Participant's Name (please print clearly) Date

FOR PARTICIPANTS UNDER THE AGE OF 18 OR LEGALLY INCAPACITATED Undersigned parent, or legal guardian or legal representative acknowledges that he/she is not only signing this Agreement on his/her behalf, but that he/she is also signing on behalf of the minor or legally incapacitated adult and that the minor or the legally incapacitated adult shall be bound by all the terms of this agreement. Additionally, by signing this agreement as the parent, or legal guardian or legal representative of a minor or legally incapacitated adult, the parent, legal guardian or legal representative understands that he/she is also waiving rights on behalf of the minor or legally incapacitated adult that the minor or legally incapacitated adult otherwise may have. The Undersigned parent, or legal guardian or legal representative agrees that, but for the foregoing, the minor or legally incapacitated adult would not be permitted to participate in the activities. If signing as the parent, legal guardian or legal representative of a minor or legally incapacitated Participant, signing adults represent that they are a parent, legal guardian or legal representative of the Participant.

Minor’s DOB Parent/Legal Guardian or Representative Signature Parent/Legal Guardian or Representative Name Relationship Date

MEDIA RELEASE FORM MEDIA/PHOTO WAIVER: Undersigned authorizes and gives full consent to Released Parties to copyright and/or publish for public view any and all photographs, digital recordings, videotapes and/or film in which Participant appears. Undersigned agrees that Released Parties may transfer, use, or cause to be used, these digital recordings, photographs, videotapes, or films for any exhibitions, public displays, publications, commercials, art and advertising purposes, television programs, and internet without limitations or reservations.

Participant’s Signature Participant's Name (please print clearly) Date

Parent/Legal Guardian or Representative Signature Parent/Legal Guardian or Representative Name Relationship Date

Disabled Sports USA – Revised 09/2015 SQUAW VALLEY® | ALPINE MEADOWS® SPORTS ACTIVITIES

RELEASE OF LIABILITY AND INDEMNITY AGREEMENT 1. I or my child (collectively, “I,” “ me,” or “my”) have voluntarily applied to participate in winter activities, summer activities, and all other associated recreational activities at Squaw Valley Resort and/or Alpine Meadows Resort. I understand that these activities can be DANGEROUS AND INVOLVE THE RISKS OF INJURY AND DEATH. These activities include but are not limited to skiing, snowboarding, ice skating, tubing, racing, roller skating, roller blading, hiking, biking, zip lining, slack lining, climbing, and dry land training; as well as participation in mini-snowmobile use, lagoon/pool/spa use, yoga, tennis, broomball, hockey, disc golf, special events, instruction, and/or any other recreational activities offered at Squaw Valley Resort and/or Alpine Meadows Resort (collectively, “Sports”). GUEST NAME 2. I understand that the Sports involve numerous risks including, but not limited to, including, but not limited to, the risks posed by changes in terrain and snow conditions; surface and subsurface snow conditions; icy, fi rm, or hard snow; unmarked obstacles; thin snow cover; bare spots; bumps; moguls; stumps; forest growth and debris; erosion control devices; rocks; cliffs; steep terrain; deep snow; avalanches and avalanche debris; and other hazards, whether the risks are obvious or not. I also understand that the Sports involve risks posed by loss of balance; loss of control; falling; sliding; and collisions with trees, rocks, fences, racing gates, fi nish posts, timing equipment, terrain features (natural or man-made), other participants and/or spectators, snowmaking or snowgrooming equipment and their components, snowmobiles and other over snow vehicles, and all manmade or natural obstacles (padded or not) whether they are obvious or not. Other risks include steep, slippery, and uneven roads and trails containing ledges, sand, mud, grass, water bars, bumps, ruts, and brush (all of which can be hidden or obscured by vegetation). I further agree that my equipment must be in good condition, but even so it poses risks to me if it develops problems during use. I understand that falls are common while participating in the Sports and during use of the facilities. Minor injuries can become life threatening when they occur far away LAST, FIRST: from rescue personnel or when alone. I understand that it may take a signifi cant amount of time for rescue personnel to locate and reach an injured person. 3. I understand that if I enter a terrain park, I should read the sign(s) at the entrance to the park. I must inspect the elements and terrain before I ski or ride over them to evaluate the risks and degree of diffi culty before participating. I understand that throughout the day snow conditions and terrain features will change. I am solely responsible for knowing and understanding my ability to encounter all terrain features. 4. Despite the risks involved in the Sports and as consideration for being allowed to participate in the Sports, I AGREE TO EXPRESSLY ASSUME ANY AND ALL RISK OF INJURY OR DEATH that might be associated with my participation in the Sports and use of the facilities at Squaw Valley Resort and/or Alpine Meadows Resort including, but not limited to, terrain parks and their features, the High Camp premises, chairlifts, the Tram, the Funitel, and other mountain transportation, rental equipment, and traveling beyond any ski area boundary (collectively in this agreement, “use of the facilities” or “use the facilities”). 5. I AGREE TO RELEASE FROM LIABILITY AND TO NEVER SUE Squaw Valley Resort, LLC, Alpine Meadows Ski Resort, LLC, Squaw Valley Ski Holdings, LLC, Squaw Valley Real Estate, LLC, Squaw Creek Associates, LLC, California Tahoe Conservancy, the U.S. Department of Agriculture Forest Service, and their respective owners, investors, members, landowners, sponsors, and parent, subsidiary and affi liated companies, and all their respective managers, directors, employees, agents, representatives, and contractors (collectively in this agreement, “Ski Area”) for any damage, injury or death to me arising from participation in the Sports or use of the facilities, regardless of cause, including the alleged NEGLIGENCE of the Ski Area. 6. I understand that this release of liability will prevent me, my child, and my heirs from fi ling suit or making any claim for damages in the event of injury or death arising from my participation in the Sports or use of the facilities. I understand this is a release of liability that will apply whenever I participate in the Sports or use the facilities. If I, my child, or any legal representative fi les a claim or a lawsuit arising out of my participation in the Sports or use of the facilities, I AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS the Ski Area for any damages, attorney’s fees or costs arising out of such a claim or a lawsuit. 7. Any pass/ticket received in conjunction with this agreement is not transferable and may only be used by the participant. If I am provided with or rent equipment with the activities, I accept the equipment “as is” and accept full responsibility for the care of the equipment while in my possession. I agree that I am responsible for the full replacement value of equipment not returned. I agree to pay for any damage that exceeds normal wear and tear. 8. he Ski Area routinely collects images, content and data for commercial purposes and patrons may be readily identifi able in these images, content or data. I grant exclusive permission to the Ski Area to use my likeness and my content for the purpose of publicity, public relations, social media sharing or other commercial purposes without compensation and without restriction as to frequency and duration. 9. MINORS: In the event of a medical emergency to my child, I authorize the Ski Area to provide emergency fi rst aid treatment and/or refer treatment to a duly licensed physician, dentist or other medical care to my child. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my child. I understand that my child may be riding lifts alone or with other children or adults while enrolled in group lessons or semi-private lessons. Please advise a supervisor if you do not want your child to ride a chairlift. 10. I agree that this agreement is severable and that if any clause is found to invalid, the balance of the contract will remain in effect, valid, and enforceable. I agree that any action arising from or related to this agreement must be brought only in Placer County (state court) or the U.S. District Court for the Eastern District of California (federal court) as venue. This agreement is subject to and interpreted under the laws of the State of California.

ADULT PARTICIPANT PRINT DOB SIGNATURE DATE

PARTICIPANT’S SPOUSE PRINT DOB SIGNATURE DATE Prospective participants under the age of 18 years are required to have a parent or legal guardian read and also sign, verifying that he/she is the parent and/or legal guardian of the minor, that the minor is in good health, and that there are no special problems associated with the care of the Child.

PRINT NAME OF MINOR NO. 1 DOB AGE PRINT NAME OF MINOR NO. 2 DOB AGE PRINT NAME OF MINOR NO. 3 DOB AGE PRINT NAME OF MINOR NO. 4 DOB AGE

SIGNATURE OF PARENT/LEGAL GUARDIAN DOB DATE

EMAIL PHONE THIS IS A RELEASE OF LIABILITY DO NOT SIGN IT UNLESS YOU AGREE TO BE BOUND BY ITS TERMS