In the following section, please answer each question. If the answer is none or does not apply to your camper, answering "none" is acceptable or "N/A"
IMMUNIZATIONS
Please input dates for the immunizations listed below. If you are unsure of the exact date, but know the Camper has received the immunization, please input “Y” in the “DATE” field. If the Camper has not received the immunization, or you are unsure, please leave the field empty.
Because our camp programs have a potential for communicable diseases, we recommend that program participants are appropriately immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, pertussis (whooping cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief).
If Camper has NOT been fully immunized for biophysical or personal choice reasons. Please sign the following statement: I understand and accept the risks to my child from not being fully immunized.
AUTHORIZATION FOR MEDICAL CARE
I, the parent (guardian) of the camper named on this form, give permission for the named camper to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that good faith 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 sole insurance coverage for any medical treatment. I further agree that my child can receive over the counter remedies. (Tylenol, Sudafed, etc.)
On behalf of myself and the Camper, I acknowledge and agree as follows:
I give permission for Camp staff to administer the following Over-the-Counter (OTC) medications and treatments consistent with medication directions.
THIS IS A RELEASE. BY SIGNING BELOW, YOU AND YOUR CHILD WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. PLEASE READ IT CAREFULLY.
In consideration of the Camper participating in the Camp and its related activities, and as a condition thereof, I am signing this Release of Liability and Indemnity (this “Release”) on behalf of myself and the Camper. This Release is made in favor of USBSA, LLC, the entity operating the Camp, and the owner of the facility at which the Camp is operated (and their respective directors, officers, employees, officials, affiliates, sponsors, hosts, agents, assigns, subsidiaries, owners, partners, and joint venturers) (collectively, the “Released Parties”).
On behalf of myself and the Camper, I acknowledge and agree that:
I HAVE READ THE INFORMATION PACKET AND FULLY UNDERSTAND OUR OBLIGATIONS STATED THEREIN AND ALSO THE RIGHTS OF USBSA, LLC (USBSA), AND HERBY AGREE TO ACT IN ACCORDANCE. For good and adequate consideration, which I acknowledge I have received, I hereby grant, release, and quit claim to USBSA royalty free the right and authority to use, reproduce, and distribute, quoted material, my child’s photograph, likeness, recorded voice, or videotaped filmed appearances (the "Materials") for promotional and advertising purposes as USBSA in its sole discretion will deem appropriate.
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 THE EVENT OF ANY DISPUTE PERTAINING TO ANY PROVISION OF THIS AGREEMENT, OR PERTAINING TO THE SERVICES RENDERED PURSUANT TO THIS AGREEMENT, OR IN ANY WAY RELATED TO ATTENDANCE AT THIS CAMP, INCLUDING ANY CLAIM FOR PERSONAL INJURY OR OTHER LOSS, INCLUDING ANY CLAIM AGAINST USBSA, USSC, THE ENTITY OPERATING THE CAMP AND THEIR DIRECTORS, OFFICERS, OFFICIALS, AFFILIATES, EMPLOYEES, SPONSORS, HOSTS, OR AGENTS, AND ALL SUBSIDIARIES, OWNERS, PARTNERS, JOINT VENTURERS, OFFICIALS, EMPLOYEES, OR AGENTS OF THE CAMP, OR OF ANY FOREGOING ENTITY, OR OF THE HOST FACILITY, SPONSOR OR INSTITUTION. EACH PARTY HERETO AGREES TO SUBMIT TO BINDING ARBITRATION TO RESOLVE SUCH DISPUTES, BY CLAIM FILED, BEFORE JAMS IN SAN FRANCISCO, CALIFORNIA, TO BE ARBITRATED HERE OR SUCH OTHER VENUE AS DEEMED APPROPRIATE BY THE JAMS ARBITRATOR, SUCH ARBITRATION TO PROCEED UNDER THE JAMS RULES. In the event either party to this agreement incurs any expense as a result of the other party’s failure to comply with any provision of this agreement, the non-complying party shall be liable for reimbursement of any and all such expenses or attorney fees directly or indirectly related to failure to comply. In the event any legal action or proceeding occurs which is in any manner related to or pertaining to this agreement, attempting to challenge in a non-arbitral forum such as a court of law the validity or application of this agreement, the party who substantially prevails in that court or non-arbitral proceeding shall be entitled to receive reasonable costs of such action or proceeding including attorney’s fees. In the arbitration itself, each party shall bear its own attorneys’ fees. The following disclosures are intended to help you thoroughly understand the significance of agreeing to arbitrate any controversy, or claim, or issue in any controversy or claim which may arise between the undersigned client and the attorney:
BY SIGNING BELOW, YOU ARE SIGNIFYING UNDERSTANDING AND ACCEPTANCE OF THE PROVISIONS OF THIS AGREEMENT.
I hereby certify that the above-mentioned participant is in good health and fully able to participate in all activities of the Camp. By signing below, I am stating that I am also aware of and accept the risk inherent in the program activity. By signing below, I agree as well to hold harmless and indemnify USBSA and USSC, their officers, directors, owners, officials, affiliates, agents and employees, and all subsidiaries from any and all liability, loss, damages, costs, refunds or expenses which are sustained, incurred or required out of the actions of my dependent in the course of the camp.