UCiC Winter Camp: 2021

Please Read:

By signing below, you confirm your understanding that in a continued effort to ensure the well-being of our children and staff, UCiC will follow all recommendations put in place by the Washington State Department of Health, the CDC and Snohomish Health District. This means that all UCiC's 2021 Winter Programs are subject to change at any time. UCiC will notify families of any changes as soon as possible. These changes could include a cancellation of the program in correlation with the ever changing Covid-19 health pandemic.

Student Name *

Parent Name *

Date * +

Parent Signature *

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Participant

Participant Information

Full Name *

Birth Date (must be 5 or older by August 31st, 2021) * +

Grade Entering in September 2021 *

Program *

Winter Camp

Fee ($):------

Weeks Attending? *

Week 1(December 20th - 23rd)

Week 2 (December 27th - 30th)

Total Fees for all Participants:

0.00

Household / Adult Primary Contact

Relationship to Participants: *

Parent

Guardian

Other Other

First Name *

Last Name *

Phone *

Email Address *

Occupation *

Address 1 *

Address 2

City *

State *

Zip *

Relationship to Participants: *

Parent

Guardian

Other Other

First Name *

Last Name *

Phone *

Email Address *

Occupation *

Address 1 *

Address 2

City *

State *

Zip *

Emergency Contact

Relationship to Participants: * 🛈

Aunt/Uncle

Grandparent

Family Friend

Neighbor

First Name * 🛈

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email Address *

Relationship to Participants: * 🛈

Aunt/Uncle

Grandparent

Family Friend

Neighbor

First Name * 🛈

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email Address *

Dietary Preference

Meat Products Do NOT give my child: *

Reason:

Preference

Digestive Issues

Allergies Allergies

Dairy Products Do NOT give my child: *

Reason:

Preference

Digestive Issues

Allergies Allergies

Grains & Sweets Do NOT give my child: *

Reason:

Preference

Digestive Issues

Allergies Allergies

Allergies My Child has the following serious food allergies:

Parent Signature *

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Health Information

Doctor Information:

Doctor's Name *

Phone # *

Hospital *

Address *

Dentist Information:

Dentist's Name *

Phone # *

Address *

Insurance Information:

Company *

Policy *

Group *

Does your child have any of the following medical conditions? (Please select all that apply)

Any other health conditions or allergies we should know about?

MEDICAL RELEASE:

Hospitals may be reluctant to treat or care for children without consent from a parent or guardian. This can cause delay in treatment if there is a medical emergency when parent(s) or guardian(s) is not available to give consent. Therefore we require your signature on this statement. If a 911 call is needed, the aid car will take the student to Swedish Edmonds Hospital.

I authorize and consent to medical, surgical and hospital care, treatment, and procedures to be performed for my child by a licensed physician or hospital when, in the sole discretion of the attending physician, such care, treatment, and procedures are immediately necessary or advisable in the interest of my child’s health and well-being, after the school has made every effort to contact me.

Under the circumstances set forth above, I elect not to be informed in advance of the nature and character of the proposed treatment, its anticipated results and possible alternatives, and risks, complications, and anticipated benefits involved in the proposed treatment and the alternative forms of treatment, including non-treatment. (The preceding statement is from Swedish Edmonds Hospital.)

Student Name *

Parent Name *

Date * +

Parent Signature *

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Waiver and Liability Form

WAIVER, RELEASE, ASSUMPTION OF RISKS & INDEMNIFICATION: I, the parent or legal guardian of the camp participent agree as follows: I acknowledge and understand that certain activities, including, but not limited to, use of playground equipment, field trips and other UCiC activities, can be hazardous and may result in injury, including loss of life. I voluntarily assume any and all risks of loss, damage or injury while my student is on the premises. In consideration for student participation, I represent that I am the parent or legal guardian and hereby release and forever discharge UCiC Learning Center, Community Church of Seattle, their volunteers, employees, directors, trustees and all other persons or entities acting on their behalf (collectively referred to as “UCIC, Community Church of Seattle”), from any and all claims, actions, damages, liabilities, costs or expenses and attorney fees which are related to, arise out of, or are in any way connected student’s viewing or participation in any activities.

By signing this Agreement, it is my intention to waive any rights I may otherwise have to sue or seek damages from UCIC, Community Church of Seattle; except where injury, death or disability results from UCIC, Community Church of Seattle’s gross negligence.

I further agree to indemnify, hold harmless and defend UCIC, Community Church of Seattle against any and all claims for damages, costs, expenses or attorneys fees brought by any third party in connection with or arising out of Student’s involvement or participation. Moreover, in consideration for Student’s participation in activities, including the use of equipment and facilities, I further agree to indemnify and hold UCIC, Community Church of Seattle harmless from any and all claims which are brought by, or on behalf of Student and which are in any way connected with such use or participation by Student. This Agreement shall be effective and binding upon my marital community, estate, heirs, agents, personal representatives and assigns.

EMERGENCY CONSENT: My Child may receive emergency or routine medical care from a licensed physician or emergency facility if I cannot be reached in an emergency situation. Such emergency or routine care includes emergency surgery, administration of medications or other measures as determined necessary by a licensed physician. I agree to assume the responsibility for all medical, transportation and rescue-related expenses incurred on behalf of Student.

Student Name *

Parent Name *

Date * +

Parent Signature *

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Asthma	Diabetes
Heart Disease	Tuberculosis
Epilepsy	Kidney Disease
Blood Disease	Hepatitis B or C
Other Other