Camp Fee Worksheet

2014 Alpine Camp Application Mt. Hood, June 30 – July 10
Please complete, sign and return all forms and the below Camp Fee Worksheet and include payment by check or credit card for the total fees as set forth in
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the Camp Fee Worksheet, along with a copy of athlete’s medical insurance card by May 1 to: WVBBTS/SEF. Attn: Rosemary Landi-2014 Alpine Mt Hood
Camp, PO Box 277, Waterville Valley, NH 03215. By signing this form, you agree to and acknowledge the following:
1.
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4.
All fees and charges hereunder are non-refundable.
You and/or your athlete(s) are not enrolled until we have received your deposit and all applicable forms filled out
completely. The information in this application, including your e-mail address, will be used for the WVBBTS/SEF mailings,
newsletters, e-mail distribution lists and other WVBBTS/SEF communication.
The undersigned hereby grants Waterville Valley Black and Blue Trail Smashers Snowsports Education Foundation, Inc.
(WVBBTS/SEF) d.b.a. Waterville Valley Academy and WVBBTS/SEF Snowsports Club the right to obtain and/or use my and
my child’s photograph, digitized image, video and/or voice recording for marketing, public relations, educational and
information purposes.
WVBBTS/SEF Code of Conduct.
Athlete(s) Information
Athlete Name
USSA #
Birth Date
Email (Required)
Athlete(s) Contact Information (Required)
Home Address
City
Mailing Address
City
Home Phone #
WV Address
State
Athlete(s) lives with
Zip
State
Zip
Father Mother Both
WV Phone #
Guardian
Father / Male Guardian Information
Name
Email (required)
Work Phone #
Home Phone #
Cell Phone #
Home Address (if different)
Mother / Female Guardian Information
Name
Email (required)
Work Phone #
Home Phone #
Cell Phone #
Home Address (if different)
Camp Fee Worksheet
To reserve your spot, you MUST include a deposit of $500
Mt. Hood Alpine Camp – June 30 – July 10,2014 (CAMP Only, airfare NOT included)
$2,500
*Please check here if you are only including $500 Deposit
Total Amount Due
CHECK OFF PAYMENT TYPE:
CHECK
AMEX
VISA
MASTERCARD
Credit Card Authorization: I authorize the “Total Amount Due” in WVBBTS/SEF Fees worksheet above to be charged to my credit card.
Name on Card
Card Number
Signature
Exp. Date
CSV #
Date
WVBBTS/SEF Code Of Conduct
You hereby agree that you and any family members participating in a WVBBTS/SEF Summer Camp have
reviewed the WVBBTS/SEF Code of Conduct set forth below and that each such participant hereby agrees to
be bound thereby. WVBBTS/SEF Snowsports Club athletes are required to abide by the following requirements
in their daily conduct:
- To adhere to WVBBTS/SEF core values of: Integrity, Teamwork, Learning, and Excellence
- Promptness and honesty
- Respect for Waterville Valley Ski Area and WVBBTS/SEF property and facilities, including without limitation,
cleaning up after oneself in the WVBBTS Clubhouse and Competition Center
- Respect for official decisions
- Support of WVBBTS staff, coaches and teammates
- Good manners (including lack of use of profanity), courtesy and thoughtfulness
- Positive attitude and outlook
- Good sportsmanship
- No use of alcohol, tobacco, illegal drugs, controlled substances or intoxicants
- Respect for WVBBTS/SEF staff, teammates, competitors and members of the Waterville Valley community at
large and other communities visited during competitions and camps
- Observation of any additional rules established by WVBBTS/SEF coaches from time to time both on and off
the hill
- Observation of all rules and regulations of Waterville Valley Ski Area and other ski areas where competitions
take place
- Agreement to help WVBBTS/SEF coaches as requested (e.g.-side slipping of course, putting away
equipment, etc.)
Signature of Athlete #1
Printed Name
Date
Signature of Athlete #2
Printed Name
Date
Signature of Athlete #3
Printed Name
Date
Signature of Mother or Legal Guardian
Printed Name
Date
Signature of Father or Legal Guardian
Printed Name
Date
2014 Summer Camp Athlete Health Summary and Medical Release Form
(Complete one form for each athlete enrolling in a BBTS camp)
This form constitutes a health summary, permission statement and medical release form that must be signed by the parents
or legal guardians of the below named athlete (“Athlete”) participating in the camp and Athlete. This form must be
completed, executed and returned to WVBBTS/SEF with the Camp Application.
Athlete Information
Athlete Name
Contact #1 – Full Name
Home Phone
Emergency Contacts
Relationship
Cell Phone
Contact #2 – Full Name
Home Phone
Relationship
Cell Phone
Contact #3 – Full Name
Home Phone
Relationship
Cell Phone
Emergency Contacts
Physician’s Name
Phone
Date of last physical exam
Insurance Coverage of Attendee
Identification #
Policy #
Expiration Date
Company
Phone
Athlete Medical Information
Medical Conditions & Restrictions(please include any Dietary requirements and or restrictions)
Allergies (please include any food allergies)
Medication
Contact Lenses
Yes
No
Dental Appliances
Yes
No
Date of last tetanus
Please send a photocopy of the athlete’s medical insurance card (both sides)
Permission to Disclose Information/Athlete Medical Release
(The first paragraph of this section does not apply to athletes ages 18 and older)
The undersigned parents or legal guardians of Athlete hereby authorize the WVBBTS/SEF Snowsports Club and
the Waterville Valley Black and Blue Trail Smashers Snowsports Educational Foundation (collectively,
“WVBBTS”), and/or their respective coaches, employees, agents or other personnel (“WVBBTS Personnel”) to
secure any emergency transport, hospital, medical, dental or surgical care, treatment and/or procedures for the
above named Athlete. The undersigned parents or legal guardians also consent that in the event of injury to the
Athlete, that one of the WVBBTS/SEF Personnel can sign for Athlete to receive care, treatment and/or
procedures, under the instructions and directions of the licensed physicians on call at the emergency room of the
nearest hospital or emergency facility. One of the WVBBTS/SEF Personnel shall notify one of the undersigned
parents or legal guardians of Athlete at the earliest possible time during or after such care, treatment and/or
procedures take place. The undersigned parents or legal guardians of Athlete knowingly and voluntarily consent
in advance to such care, treatment and/or procedures to encourage the physicians and WVBBTS/SEF Personnel
to exercise their best judgment as to the requirements of such care, treatment and/or procedures. The
undersigned parents or legal guardians of Athlete specifically indemnify and hold harmless WVBBTS/SEF and
the WVBBTS/SEF Personnel from any and all costs arising out of such care, treatment and/or procedure.
The undersigned parents or legal guardians of Athlete hereby grant permission for this Health Summary and
Medical Release Form to be released to those WVBBTS/SEF Personnel or other appropriate health care
providers who may need this information in order to treat Athlete in a medical emergency. In addition, the
undersigned parents or legal guardians of Athlete hereby grant permission, in the event of a medical emergency
for WVBBTS/SEF Personnel or other appropriate heath care providers to contact Athlete’s primary care physician
and to obtain access to the Athlete’s medical records. Except as provided in this paragraph above,
WVBBTS/SEF shall keep this Health Summary and Medical Release Form in confidence.
Insurance Requirements
WVBBTS/SEF requires that WVBBTS/SEF Summer Camp participants be covered by a valid and sufficient
medical insurance policy. Athlete will provide a copy of his or her medical insurance card evidencing such
insurance policy to WVBBTS/SEF for WVBBTS/SEF to keep on file. The Athlete must carry proof of this
insurance and have it available at each training session, competition or camp so that prompt medical care can be
obtained, if ever needed.
Further Agreement
The Undersigned have read and understood the Insurance Requirements statement above. The insurance policy
listed above meets the requirements of WVBBTS/SEF and will be maintained in force while Athlete is
participating in Snow Sports Activities with WVBBTS/SEF. The Undersigned agree that the Undersigned are
responsible for any and all medical charges and the Undersigned agree that they will promptly reimburse
WVBBTS/SEF for any expenses that WVBBTS/SEF or the WVBBTS/SEF Personnel incur on behalf of the
Athlete.
Signature of Athlete
Printed Name
Date
Signature of Mother or Legal Guardian
Printed Name
Date
Signature of Father or Legal Guardian
Printed Name
Date
WVBBTS/SEF Club Release, Assumption of Risk and
Hold Harmless and Indemnity Agreement
(Complete one form for each athlete enrolling in a WVBBTS/SEF Summer Camp, it being understood that where the
athlete is ages 18 and older that the names, signatures and references to parent or legal guardian do not apply.)
The undersigned parents or legal guardians of ___________________________ (“Athlete”) and the
undersigned Athlete (collectively, the “Undersigned”), understand and acknowledge that skiing and
snowboarding in their various forms as well as training, competition, camps, travel to and from such
activities and related activities with respect thereto while taking part in the WVBBTS/SEF Snowsports
Club training program regardless of the location of such activities (collectively, “Snow Sports Activities”)
may (i) place Athlete’s life, health and physical well-being at serious risk for personal injury or death and
(ii) involve many inherent risks, dangers and hazards. These risks, dangers and hazards include, but
are not limited to, changing weather and snow conditions, variations in steepness and terrain, natural
and man-made obstacles and structures, equipment failure, collision with objects or structures or being
struck by skiers/riders or equipment and exceeding Athlete’s own abilities.
In consideration of Athlete being permitted to participate in the WVBBTS/SEF Snowsports Club training
program and participate in Snow Sports Activities at Waterville Valley Ski Area and other locations, the
Undersigned, agree to ASSUME ALL RISKS associated with Athlete participating in Snow Sports
Activities and other activities while participating in the WVBBTS Snowsports Club training program. The
Undersigned also agree to (i) WAIVE AND RELEASE ANY AND ALL PRESENT AND FUTURE
CLAIMS, against the WVBBTS Snowsports Club, Waterville Valley Black and Blue Trail Smashers
Snowsports Educational Foundation and their respective agents, employees, coaches, directors,
officers, owners and volunteers (collectively, “WVBBTS/SEF and its Personnel”), due to any cause
whatsoever associated with Athlete participating in Snow Sports Activities and other activities while
participating in the WVBBTS/SEF Snowsports Club training program and (ii) DEFEND, INDEMNIFY
AND HOLD HARMLESS BBTS and its Personnel from any and all PRESENT AND FUTURE CLAIMS,
that may occur as a result of Athlete’s participation in Snow Sports Activities or other activities while
participating in the WVBBTS/SEF Snowsports Club training program. The Undersigned acknowledge
that with Athlete as a participant, Undersigned must take an active role in understanding and accepting
these risks, conditions and hazards.
Signature of Athlete
Printed Name
Date
Signature of Mother or Legal Guardian or Masters
Racer
Printed Name
Date
Printed Name
Date
Signature of Father or Legal Guardian or Masters
Racer
TIMBERLINE LODGE & SKI AREA AGREEMENT OF
RELEASE AND INDEMNITY
GROUP/EVENT/CAMP/SHOP NAME:
NAME OF PARTICIPANT:
ADDRESS:
AGE:__________ PHONE:
CITY:
STATE:
ZIP:
_
Please read carefully! This is a release of liability and waiver of certain rights .
I understand that skiing, snowboarding, snowskating, bicycling, racing, the use of chairlifts, the use of terrain parks and jumps,
the mountain environment, commercial filming, sports event production, sports events, snowmobiles, snowcats, vehicle shuttle
transportation, and any other sports or related activities, including training for such activities (collectively referred to as "Sports
Activities") are hazardous and that injuries are common. I have made a voluntary choice to participate in such Sports Activities
(or to allow my child to do so) despite the risks that they present. I hereby voluntarily agree to assume all risks associated
with Sports Activities.
In consideration for lift access, participation in Sports Activities, and the use of any other area facilities,
premises, or equipment, I hereby agree to release, hold harmless, and indemnify R.L.K. and Company, dba
Timberline Ski Area and its members, directors, officers, employees, affiliates, contractors, volunteers,
organizers, sponsors, and agents (collectively referred to as "Timberline") from any and all claims by me or on
my behalf against Timberline arising directly or indirectly out of my participation in Sports Activities
and/or the use of any area facilities, premises, or equipment. This r e l e a s e i n c l u d e s claims a n d liabilities
arising from any cause whatsoever, including, but not limited to, negligence on the part of Timberline. I also
agree to indemnify (including costs and attorney fees) Timberline for any claim brought on behalf of any
minor Participant.
I agree to abide by the Skier Responsibility C o d e , ORS 30.990, and any rules, regulations, directions, signage, warnings,
and/or orders of Timberline. If I do not, I understand that Timberline may, among other things, revoke my Sports Activities
privileges.
In the event of any claims or litigation arising out of or in connection with participation in any activity at Timberline Ski Area, the
venue for legal proceeding shall be Clackamas County, Oregon. If any term is declared to be invalid hereunder, the remaining
terms of this Agreement shall continue to be enforceable. This Agreement is governed by Oregon law.
I hereby irrevocably grant and convey to Timberline all right, title and interest in and to record my name, image, voice, statements
and/or writings including any and all photographic images and video or audio recordings at Timberline Lodge and Ski Area. I
further irrevocably grant to Timberline unrestricted rights to use the above mentioned sound, still, or moving images in any
medium, including posting on the internet and world wide web, for educational, promotional, advertising, or other purposes without
limitation consistent with the mission of Timberline. I agree that all intellectual property rights to the sound, still, or moving
images belong to Timberline. I voluntarily waive the right to inspect or approve such images and waive my right to any
royalties, proceeds or other benefits derived from such photographs or recordings.
I have carefully read and understand this Agreement and all of its terms. I understand that this is a release. I enter into this
Agreement voluntarily and understand that it is binding upon me and my heirs and representatives.
PARTICIPANT'S NAME:
PARTICIPANT'S SIGNATURE:.
(Please print)
DATE:
PARENT OR GUARDIAN OF PARTICIPANT (must be signed by parent or legal guardian if Participant is under eighteen (18) years of age.)
AS PARENT OR GUARDIAN OF THE NAMED PARTICIPANT, I HEREBY AGREE TO THE INDEMNITY PROVISIONS REFERRED TO
ABOVE AND I WILL BE RESPONSIBLE FOR THE PAYMENT OF ANY MEDICAL EXPENSES INCURRED BY THIS MINOR.
PARENT OR GUARDIAN
NAME:
EMERGENCY CONTACT PHONE
#:
PARENT OR GUARDIAN
(Please print) SIGNATU”RE:______________________
_______