Summer Camp 2024- Student Form
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Email *
What Program is the child enrolled in? *
Student Full Name *
Student Date of Birth *
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Gender *
Student Age *
Student Street Address *
Please list if student has any allergies or medical conditions. *
Please list medications. Write none for no medications. *
Emergency Contact name and number *
Father/Guardians Full Name *
Father/Guardians Phone Number *
Mother/Guardians Full Name *
Mother/Guardians Phone Number *
ACCIDENT WAIVER AND RELEASE OF LIABILITY STATEMENT
I hereby assume all of the risks participating in any and all water activities with the VRIC Summer Camp, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of possible liability without fault.

I certify that my child is physically fit and has not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude his/her participation in the VRIC Summer Camp field trip at the Grapevine Lake. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the organizers of the VRIC Summer Camp in which my child may participate and that it will govern his/her actions and responsibilities at the VRIC Summer  Camp.

In consideration of this application and permitting my child to participate at the VRIC Summer Camp field trip, I hereby take action for myself, my child, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

 
(A)  I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my child's death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to my child including traveling to the field trip at Grapevine Lake. THE FOLLOWING ENTITIES OR PERSONS: ALL associated with the Valley Ranch Islamic Center Summer Camp, and/or their coaches, agents, representatives, or volunteers.
 
 
(B)  I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in all Camp activities including water activities, whether caused by negligence or otherwise.
 
 
I acknowledge that the VRIC Summer Camp field trip may carry with it the potential for death, serious injury, and personal loss. The risks may include, but are not limited to, those caused by water sports and equipment, lake, water, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, and lack of hydration.

I consent and agree that the VRIC Summer Camp and/or their organizers, teachers, coaches, agents, representatives or volunteers may take photographs or digital recordings of my child as a participant during this event and use these in any and all media for training or promotional purposes. I further consent that my child’s identity may be revealed therein or by description text or commentary. I waive any rights, claims or interest and I understand that there will be no financial or other remuneration.

The accident waiver, release of liability and image release shall be construed broadly to provide a release and waiver to the maximum extent permissible under law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT ON MY OWN FREE WILL.



I agree to the above  ACCIDENT WAIVER AND RELEASE OF LIABILITY STATEMENT *
Required
Parent/ Guardian Signature- Typing of name will serve as a signature. *
Date *
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A copy of your responses will be emailed to the address you provided.
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