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