DIXIE BAND CAMP 2009
APPLICATION FORM (Please Print)
NAME_________________________________PARENT____________________________________
MAILING
ADDRESS_________________________________________________________________
CITY______________________________________
STATE________________ ZIP______________
AGE_____ SEX _____
PHONE (
) __________________________________________________
NAME OF SCHOOL
_______________________________GRADE COMPLETED MAY 2009 _____
BAND DIRECTOR
___________________________________Previous YRS. AT DIXIE ___________
YEARS STUDIED
______ YOUR INSTRUMENT (Be
Specific) ______________________________
T-Shirt
Size (Circle one) S M L
XL XXL (Adult Sizes Only)
Application deadline to receive a FREE T-SHIRT is June 1, 2009 ( If no size indicated, you will receive a Large)
ALL-STATE STUDENTS ONLY (Circle One) Concert Band Jazz Band
CAMP (check one)
ON
CAMPUS
OFF
CAMPUS
( ) SENIOR CAMP (
) $290.00
( ) $175.00
( ) JUNIOR CAMP (
) $290.00
( ) $175.00
A
minimum deposit of $175.00 must accompany this form.
Make your check or money order payable to DIXIE BAND CAMP
Applications post-marked
after June 1, 2009 will be assessed a $25.00 Late Registration Fee.
Camp Fee or Deposit ENCLOSED $ ________________
Optional (Wild River) Fee
ENCLOSED $ ________________
Late Fee ENCLOSED
$ ________________
TOTAL AMOUNT ENCLOSED
$ ________________
REQUIRED MEDICAL HISTORY & CONSENT FOR TREATMENT
FOR CAMPS AT THE UNIVERSITY OF CENTRAL ARKANSAS
Camp child will be
attending ____________________________________Dates ____________________
Campers
Name___________________________________________ Age_______ DOB ___________
Street
Address______________________________ City ____________________ State ____Zip
______
Parent/Guardian____________________________
Address _________________State ____ Zip _______
Telephone
_______________________________ Cell
Phone ___________________________________
EMERGENCY CONTACT –
In case of Emergency, if a parent cannot be reached, name of person to notify
or to whom we can release camper to in your absence.
NAME
__________________________________ Telephone __________________________________
CIRCLE ALL CONDITIONS CAMPER CURRENTLY HAS OR HAD IN
THE PAST
Constipation
Bed wetting Sleepwalking Ear problems Asthma
Seizures Diabetes Bronchitis Frequent colds Sinusitis
Nausea Vomiting Eating
disorder Heart problems
Cancer
Kidney
problems Homesickness Abdominal problems Menstrual problems
Sore throat
Other medical
conditions: ________________________________________________________________
ALLEGERIES:
Drug _________________ Bee Stings ____________________ Latex
______________
Describe physical
conditions requiring restrictions on participation in camp program:
______________________________________________________________________________________
NAME OF CAMPER’S
PHYSICIAN _________________________ TELEPHONE__________________
INSURANCE COMPANY
____________________________ MEMBER # ________________________
IMMUNIZATIONS: Last Tetanus injection
__________________________________________________
PARENT/GUARDIAN
SIGNATURE _______________________________________________________
PRINT
PARENT/GUARDIAN NAME_______________________________________DATE _________
MEDICATION CONSENT FORM
If medication
consent form is not fully completed, medications will not be administered to
the camper.
CURRENT MEDICATIONS
WITH DOSAGE SCHEDULE:
__________________________________
____________________________________________________________________________________
MEDICATIONS CAMPER
TAKES AS NEEDED, i.e. Tylenol, Ibuprofen, Midol, Tums, Benadryl, Claritin,
Cough medication, Skin creams:
______________________________________________________________________________________
REQUIRED PARENT/GUARDIAN CONSENT
I understand that I
am giving consent for my child to receive treatment for minor illnesses and
injuries as directed by the Advanced Practice Nurses in the Health Clinic. This medical history/medication consent form
is correct as far as I know and I understand that both forms must be filled out
COMPLETELY in order for my child to receive treatment at a UCA Camp. I understand that in case of an emergency,
every effort will be made to contact a parent or guardian prior to
treatment. However, if the parent or
guardian cannot be reached and the situation requires immediate emergency
attention as determined by the camp staff or by the clinic staff, I hereby
authorize representatives of the camp to obtain emergency treatment for my
child as deemed necessary and I agree to the release of any records necessary
for the treatment or referral of the minor child.
MEDICATIONS,
PRESCRIPTIONS: Arkansas State Laws requires
parental authorization to administer any prescription medications brought by
campers. Prescribed medications MUST be
in its original container with the pharmacy label showing number, patient name,
date filled, physician name, name of medication and directions for use.
I authorize
______________________________, my child; to take his/her own medication or the
camp health supervisor to administer to my child any prescribed medications
being brought to camp.
NON-PRESCRIPTION
MEDICINES: I authorize my child to take
his/her own over-the-counter medications.
YES NO
I authorize the
health care designee to administer the non-prescription medications as deemed
necessary for the camper’s comfort, as listed above. YES NO
PARENT SIGNATURE
_________________________________________________________________
AGREEMENT FOR ASSUMPTION OF RISK & RELEASE
INDIVIDUAL PARTICIPANT RELEASE
I,
_________________________________, the undersigned, being allowed to use the
facilities of the University of Central Arkansas (hereinafter “University”) for
activities related to Dixie Band Camp (hereafter “the event”), on June 2009, do
hereby release and forever discharge the University and Dixie Band Camp Inc.,
and all of their officers, agents, employees, trustees, and /or successors in
interest, from and against any and all claims of damages, demands, and actions,
or causes of action, on account of damage to personal property, personal
injury, or death which may result from my participation. Specifically, I release the University and
Dixie Band Camp Inc. and all of their officers, agents, employees, trustees,
and/or successors in interest from any claim against them, which relates to my
participation in activities related to the event while on the campus of the
University. I acknowledge for myself
that I am the recipient of a privilege from the University and Dixie Band
Camp. I understand that privilege is a
tangible benefit to me. I also fully
understand that my participation in activities related to the event at the
University is voluntary and that I am not required to participate. I hereby attest and verify for myself that I
have full knowledge of the risks involved in participation in the event at the
University and assume those risks, and will assume and pay my own medical
expenses and emergency expenses in the event of an accident, illness, or other
incapacity. I attest that I am
physically fit and sufficiently trained to participate in the event at the
University. Should injury or illness
occur while on campus, I give my permission to receive treatment, if
necessary, from UCA Student Health
Services and/or a local Conway health-care provider at my expense.
I, for myself,
accept full responsibility for any use of all facilities, including property of
the University; and agree to make full restitution with regard to any
compensation required as a result of my participation or use, misuse, damage,
or negligence to such properties. It is
my express intent that this Agreement for Assumption of Risk and Release shall
bind my family and spouse, if I am alive, and my heirs, assigns or personal
representatives, if I am deceased, and shall be deemed as a RELEASE, WAIVER,
DISCHARGE AND COVENANT NOT TO INSTITUTE LEGAL ACTION AGAINST THE ABOVE-NAMED
RELEASEES. I HEREBY FURTHER AGREE THAT
THIS RELEASE SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF
ARKANSAS. I further hereby agree to indemnify
and hold harmless the releasees from any loss, liability, damage or costs,
including court costs and attorney’s fees, that they may incur due to my
participation in said activity, whether caused by negligence of releasees or
otherwise. In signing this Agreement
for Assumption of Risk and Release, I acknowledge and represent that I have
read the foregoing and freely and voluntarily agree to its terms. I further acknowledge that no oral
representations, statements or inducements, apart from the foregoing written
Agreement, have been made, and that I am at least eighteen (18) years of age
and fully competent. In witness
whereof, I have caused this Agreement for Assumption of Risk and Release to be
executed this _____ day of ______________, 2009.
STUDENT SIGNATURE
________________________________________________
IF THE UNDERSIGNED
IS A MINOR (UNDER 18 YEARS OF AGE), A PARENT OR LEGAL GUARDIAN MUST SIGN
THE DOCUMENT BELOW.
AGREEMENT FOR
ASSUMPTION OF RISK & REAEASE OF PARENT OR LEGAL GUARDING FOR A MINOR
I,
_______________________________, parent or legal guardian of ______________________________,
acknowledge and represent that I have read the foregoing Agreement for
Assumption of Risk and Release, and that I understand and sign it on behalf of
my minor son/daughter, voluntarily as my own free act and deed. I further acknowledge that no oral
representations, statements or inducements, apart from the foregoing written
Agreement, have been made. It is my
express intent that this Agreement for Assumption of Risk and Release shall
bind the members of my family and spouse, if I am alive, and my heirs, assigns
or personal representatives, if I am deceased, and shall be deemed as a
RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO INSTITUTE LEGAL ACTION AGAINST
RELEASEES NAMED IN THE AGREEMENT FOR ASSUMPTION OF RISK AND RELEASE ATTACHED
HERETO. I HEREBY FURTHER AGREE THAT
THIS RELEASE SHALL BE CONSTRUED IN ACCORDANCE WITH THE LAWS OF THE STATE OF
ARKANSAS. In witness whereof, I have
caused this Release of Parent or Legal Guardian for Minor to be executed this
_____________ day of ___________________, 2009.
_______________________________________________________ Parent or Legal
Guardian Signature
WILD RIVER COUNTRY INFORMATION &
PERMISSION FORM
WILD RIVER COUNTRY
has been tentatively scheduled again this year as an OPTIONAL night activity
for the 2009 JUNIOR & SENIOR SESSIONS of camp. WILD RIVER COUNTRY is a water theme park located in North Little
Rock. If you would like for your child to participate in this optional
activity, the permission form below MUST be filled out and returned along with
the $15.00 admission fee. We will not
be able to accept Wild River Country applications after 1:00 p.m. on the fist
day of camp. A parent/guardian MUST
sign this form. Students will be transported to and from WILD RIVER COUNTRY on
school busses driven by licensed drivers.
Participation in this activity is optional and alternate recreational
activities will be provided for those who choose not to participate.
I GIVE PERMISSION FOR MY CHILD,
________________________________, TO PARTICIPATE IN THE WILD RIVER COUNTRY
ACTIVITY described above.
PARENT SIGNATURE
____________________________________ DATE___________ AMT. PAID ____________
(______) ___________________ (________) _______________________
(________)_______________
Home Phone Number Father’s Work
Number
Mother’s Work Number
Mail this completed form plus your Deposit to:
DIXIE BAND CAMP, P.O. Box 19004, JONESBORO, AR 72403