Assumption of Risk Waiver Release and Consent for Non-Student Minor Participation

COCONINO COUNTY COMMUNITY COLLEGE DISTRICT
D/B/A COCONINO COMMUNITY COLLEGE

ASSUMPTION OF RISK, WAIVER, RELEASE, AND CONSENT FOR NON-STUDENT MINOR PARTICIPATION IN SUMMER CAMP (“CAMP”)

THIS DOCUMENT HAS LEGAL CONSEQUENCES. IT MUST BE COMPLETED AND SIGNED PRIOR TO PARTICIPATION. PLEASE READ IT CAREFULLY BEFORE SIGNING.

Camp Title/Description*

Camp Date(s)*

Camp Location*

Specific Potential Risks of Camp*

Department Contact Name*

Department Contact Email*

example@example.com

Department Contact Phone*

Minor/Participant Name*

First NameLast Name

Minor/Participant Age*

Parent/Legal Guardian Name #1*

First NameLast Name

Parent/Guardian 1 Email Address*

example@example.com

Parent/Guardian 1 Phone Number*

Please enter a valid phone number.

Parent/Guardian 1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Legal Guardian Name #2

First NameLast Name

Parent/Guardian 2 Email Address

example@example.com

Parent/Guardian 2 Phone Number

Please enter a valid phone number.

Parent/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name*

First NameLast Name

Emergency Contact Relationship to Student*

Emergency Contact Phone Number*

Please enter a valid phone number.

Minor will be picked up at the end of the Camp or for any authorized time spent off campus by:

Authorized Pick Up Name

First NameLast Name

Authorized Pick Up Relationship to Student

Authorized Pick Up Phone Number

Please enter a valid phone number.

Identification will be required to be show to Camp staff person who is picking up the Non-Student Minor. If the parent(s)/legal guardian(s) listed above is not the person picking up the Non-Student Minor, add name(s), relationship(s), and phone(s) of other authorized individuals below.

IN ADDITION TO THE PARENT(S)/LEGAL GUARDIAN(S) LISTED ABOVE, THE FOLLOWING INDIVIDUALS ARE AUTHORIZED TO PICK UP NON-STUDENT MINOR:

	Name	Relationship	Phone
1
2
3
4
5

Minor's Name*

First NameLast Name

In the applicable sections below, provide a complete and accurate list and description of the physical factors that may affect participation in the Camp.

Local Physician(s) preferred (if possible)*

Physician's Phone Number*

Insurance Company*

Insurance Phone Number*

Insurance Policy Number*

Insurance Group Number*

Please indicate any and all special medical conditions Coconino Community College may need to know about:

List any and all medication(s) taken on a regular basis for any reason, to include but not limited to, medication taken for illness(es), allergies, pain, and injuries; use additional paper if necessary:

List any allergies, to include but not limited to, any medications, food, insect bites, and stings, and describe allergic reactions:

List any additional medical/physical information that Coconino Community College should be aware of, to include but not limited to fitness level, ability to swim, and mobility or sensory limitations:

I affirm that I am the adult parent or legal guardian of First Name* , a Non-Student Minor under the age of eighteen (18), and I consent to their participation in this Camp. In consideration of allowing Non-Student Minor to participate in this Camp and related activities, I, on behalf of Non-Student Minor and for myself and my spouse, if any, and our heirs, successors, and assigns:

Acknowledge and understand that allowing Non-Student Minor participation in the Camp may involve a variety of activities. Such participation, particularly in field trips, “wilderness trips”, sports camps and physical education and similar events, may involve risks, including but not limited to, serious personal injury, partial or permanent disability, sickness, disease or illness, property damage, and/or death. These risks may result from Non-Student Minor’s own actions or inactions, from the actions or inactions of others, or may be inherent to participating in the Camp. I understand that I am responsible for ensuring that Non-Student Minor is properly prepared for all Camp activities, and I represent that Non-Student Minor is in good health and able to participate fully in all Camp activities. I also understand that Coconino Community College is not an agent of and has no responsibility for any third party that may provide any services during the Camp, including but not limited to, food, lodging, travel, and equipment associated with the Camp.
I acknowledge that Coconino Community College has taken enhanced health and safety measures, in accordance with guidelines from the U.S. Centers for Disease Control and Prevention, in response to the COVID-19 pandemic. An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. By participating in the Camp, I voluntarily assume all risks related to exposure to COVID-19.
Assume all the foregoing risks and accept personal and financial responsibility for all damages for personal injury, partial or permanent disability, property damage, or death, caused by me, to the fullest extent allowed by law.
Agree not to sue and to waive, release and indemnify Coconino County Community College District, their district governing board, officers, employees, agents, and assigns, for any and all claims, damages, personal injury, partial or permanent disability, sickness, disease or illness, property damage, or death, caused or alleged to be caused in whole or in part arising out of or in connection with my participation in, or travel to and from the Camp. I understand that my participation in this Camp is voluntary.
Grant to Coconino Community College and to its employees, agents and assigns the right to photograph/video Non-Student Minor and use the photograph/video and or other digital reproduction of Non-Student Minor or other reproduction of Non-Student Minor physical likeness for publication processes for use in connection with Coconino Community College Camps, whether electronic, print, digital or via the Internet.
Understand that the only medical treatment that will be provided by the Camp is for such things as minor scrapes and bruises. Any medical costs including emergency medical treatment that may be incurred as a result of Non-Student Minor’s participation in the Camp will be my financial responsibility. I further understand that medical care facilities may not be immediately available, and I accept the risk in the event of injury or death.
Hereby consent to Coconino Community College and any appropriate medical facility, and/or to the physician(s) listed below, providing whatever medical services they may deem necessary for Non-Student Minor in the event of an emergency. I certify that I have adequate insurance and/or other means to pay for any costs and expenses related to these services and I agree to bear such costs and expenses in full.
Agree to review Camp rules with Non-Student Minor and agree Non-Student Minor will comply with Coconino Community College’s rules, standards, and any specific standards of conduct of the Camp that may be provided. I understand that Non-Student Minor is not permitted to consume alcohol, possess/use weapons, or illegal substances, or engage in sexual activities while participating in the Camp. I understand that Non-Student Minor may be removed from Camp for misconduct or failure to follow rules or instructions of Coconino Community College for any behavior detrimental to or incompatible with the standards of Coconino Community College or the Camp, and I understand in the event I may not be entitled to a refund of any or all Camp fees if applicable.
Waive and release all claims against Coconino Community College, their board, officers, employees, agents, and assigns that arise at a time when Non-Student Minor is not under the direct supervision of Coconino Community College or that are caused by Non-Student Minor’s failure to remain under such supervision or to comply with rules or instructions, to the fullest extent allowed by law.
Acknowledge and understand that either the Non-Student Minor or Coconino Community College has the right to decline, decrease, or cease Non-Student Minor’s participation in the event of illness, injury, or other medical condition.
Understand that Coconino Community College may reduce or stop Non-Student Minor’s participation, in its sole discretion, in the best interest or safety or to aid in the well-being of other participants. Coconino Community College may require further assessment and medical clearance from a physician prior to participation in Camp.
ACKNOWLEDGE THAT I HAVE CAREFULLY READ THE ABOVE ASSUMPTION OF RISK, WAIVER, RELEASE, AND CONSENT FOR NON-STUDENT MINOR PARTICIPATION FORM AND UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.
No oral or written representations can or will alter the contents of this document. I agree that this document shall be governed by the laws of Arizona.

Parent / Legal Guardian Name*

Parent / Legal Guardian Signature*

Date*

Date

Hour MinutesAM/PM Option

Assumption of Risk Waiver Release and Consent for Non-Student Minor Participation

Camp Information

Minor/Participant Information

Authorized Pick Up

Minor Medical Information

Agreement