Minors in Sponsored Programs Participant Waiver

Minors in Sponsored Programs Participant Waiver

Email*

2025 Programs

My child is participating in the following Summer Camp Programs. Check all that apply.*

Select or enter value

Child's Name*

Personal Information

Child's Date of Birth*

Parent/Guardian Name(s)*

Street Address*

City*

State*

Zip Code*

Cell Phone Number*

Phone

Work Phone Number*

Phone

Home Phone Number*

Phone

Medical Information and Authorization for Medical Treatment

Name of Person to Notify in Case of Emergency*

Relationship of Emergency Contact Person to Child (Ex. Grandmother, Uncle, etc...)*

Emergency Contact Person's Phone Number(s)*

Phone

Emergency Contact Person's Address*

Family Physician*

Family Physician Phone Number*

Phone

Insurance Provider

Insurance Provider Phone Number*

Phone

Insurance Provider Policy Number*

The institution does not offer any form of health, liability, or other types of insurance for participants. Please provide a copy of the front and back of your insurance card on or before the first day of the youth program.

Please list any current medical concerns or medical history we need to know about your child: (Ex. past injuries, current conditions, physical limitations, etc.)*

List any allergies you child has (Ex. medications, stings, food, iodine, latex, etc.)*

List any medications your child is taking, their purpose, dosage, and times taken*

Does your child need require any assistance with his or her medication? If so, please explain.*

Does your child need any accommodations to safely participate in the program? If yes, please explain.*

Authorization for Medical Care

I understand that my child is voluntarily participating in a University of West Georgia program. By signing this form I hereby acknowledge that all information is accurate and current, that any activity restrictions, allergies, and medications are listed on this form, and to the best of my knowledge, my child is capable of participating safely in the program. I acknowledge that my failure to disclose relevant information may result in harm to my child and/or others during this program. I agree to notify the program of any changes in my child's mental, physical, or medical condition before the program begins. I understand that UWG does NOT provide medical insurance for my child and that I should consult my child's physician before allowing my child to participate in this program. In the case of accident or illness, I hereby authorize the program staff to administer or seek medical treatment for my child, as they see fit, including routine first aid care or emergency medical treatment. I hold harmless and agree to indemnify the University of West Georgia and the Board of Regents from any claims, causes of action, damages, and/or liabilities arising out of or resulting from said medical treatment. I acknowledge that I am solely responsible for any hospital or other costs arising out of any bodily injury or property damage sustained through my child's participation in such voluntary program.

Note: The institution does not offer any form of health, liability, or other types of insurance for participants. Please attach a copy of the front and back of your insurance card with this form.

Name of Participant*

Date*

Signature*

Signature of Parent/Guardian: I hereby certify that I am over 18 years of age and that I have read the above carefully before signing, and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns. By entering your initials on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Pick Up Authorization

Please list any individual who is authorized to pick up your child, including yourself. Each authorized person must be at least 16 years of age. The above-named child will not be permitted to leave the program with anyone who is not listed below. Authorized individuals must pick up the child in person and may be requested to show identification to program staff. Children will not be released to persons who fail to provide acceptable identification upon request.

Please note that children must be picked up by designated times. If an authorized adult is unable to be reached, program members will contact University Police as a last resort to take your child home. If you are not at home, your child will be released to the Division of Family and Children Services.

I authorize the following responsible persons to pick up my child from the program:

Authorized Person #1 , Phone Number, & Relationship to Child:*

Authorized Person #2 , Phone Number, & Relationship to Child:

Authorized Person #3 , Phone Number, & Relationship to Child:

Authorized Person #4 , Phone Number, & Relationship to Child:

Child's Name*

Parent/Guardian Name*

Signature of Parent/Guardian*

I hereby certify that I am over 18 years of age and that I have read the above carefully before signing, and fully understand its contents. This release shall be binding upon me, my heirs, legal representatives, and assigns. By entering your initials on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.

Authorized Dismissal

Authorized Dismissal - Signature of Parent/Guardian: Initial in the line below if your child is at least 16 years of age and will be responsible for his/her own transportation to and from the program. Your child may sign himself/herself out at the end of the program activities.

Media, Photo & Video Release

Media Release*

Please read the following release carefully and select one:

Yes, I give permission for my child's name, likeness, image, or voice to be used in photographic, video, digital, or other recording forms. I give my permission for the program to use those recordings or works produced by my child (e.g., artwork) for promotional, information, and educational purposes in any and all media, as deemed appropriate by the University). I understand that the image may be accessible by the general public. I further acknowledge and agree that the University cannot be responsible for any use of the image by any third party accessing the image through the internet or any other manner. I understand that neither my child nor I will receive payment or any other compensation for the taking or use of any recordings or works created as a result of my child's participation in the program. I understand that I have the right not to consent to my child being videotaped, photographed, or recorded during the program, and the right not to consent to the release or use of the image or media and any personally identifiable information about my child contained in the media, and that this consent shall remain in effect until revoked by me in writing and delivered to the University, though any such revocation shall not affect disclosures previously made prior to its receipt.

No, I do not grant permission for my child's name, likeness, image, or voice to be used in any form, unless necessary for the administration of the program while my child is participating..

Yes

Name and Age of Child*

Name of Parent/Guardian*

Signature of Parent/Guardian*

Date*

Youth Program/Camp Behavior Guidelines

Youth Program/Camp staff will make every effort to ensure all participants have a positive experience.

General Behavior Rules

• Be Kind – keep hands, feet, and objects to yourself

• Be Respectful – to staff, others, yourself, and environment

• Be Safe – stay with a camp staff member and your group

Unacceptable Behavior

• Refusing to follow the behavior guidelines or camp/program rules

• Refusal to participate in activities or cooperate with staff

• Disrupting the camp/program

• Stealing or damaging property (personal or camp/program property)

• Leaving the camp/program without permission

• Endangering the health and safety of participants and/or staff

• Using profanity, vulgarity or obscenity

• Physical violence or bullying/teasing toward another participant or staff will not be tolerated.

When Camp/Program Behavior Rules are Broken

• Staff will redirect the participant to more appropriate behavior.

• If inappropriate behavior continues, the participant will be reminded of behavior guidelines/rules and the participant will be asked to decide on action steps to correct his/her behavior.

• Staff will document the situation, the inappropriate behavior and action taken. Parents will be notified.

• If the situation is not resolved and inappropriate behavior continues, as a final action step, the participant will be dismissed from the camp/program. Dismissed participants are not eligible for a refund of any fees.

Please read the above Youth Program/Camp Behavior Guidelines and check below.*

Yes

Name and Age of Child*

Name of Parent/Guardian*

Signature of Parent/Guardian*

Date*

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