Summer Camp Detailed Registration Form 2018

2018 CRC Summer Running Camp

The CRC Running Camp is organized by the Carmichael Running Club and is not affiliated with the San Juan Unified School District or any of its schools. Participation in the camp is not a requirement for participation in any sport nor does it constitute acceptance onto any team.

This is an application only. Although we expect all interested athletes will be able to participate, priorty is given to varsity runners and upper classmen first. Every effort will be made to accommodate all runners. APPLICATION DEADLINE is Saturday, July 7th. Acceptance emails will be sent no later than Sunday, July 8th.

The total camp cost, not including any incidentals, is $200. The fee includes 4 days and 3 nights of lodging, transportation, food, paddle boarding, swimming, movies and, of course, coaching. Payment is due prior to departure. Partial scholarships are available. Please complete and submit the form then contact Coach Paul directly to inquire about a scholarship.

* Denotes "required" information

Athlete Information

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

High School*

Team*

Grade*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name*

First NameLast Name

Home Number*

Area CodePhone Number

Cell Number*

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, including food allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the athlete prescribed an inhaler or any other medications? If yes, please explain any instructions.*

Medical Insurance Information

The camp is not affiliated with Mira Loma High School or the San Juan Unified School District. Medical Insurance or payment of medical bills for any injury or illness is the responsibility of the athlete, athlete's parent / guardian. Coverage is not proivded by the camp, coaches or anyone affiliated with the camp.

Medical Provider*

Medical Insurance Coverage

Policy Number*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Carmichael Running Club during the selected camp. Camp activities include running and may include swimming, hiking and paddle boarding. Attendees are not required to participate in any activities and do so at their choice and own free will. In exchange for the acceptance of said child’s candidacy by Carmichael Runnning Club, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Carmichael Running Club, and all its respective officers, coaches, agents, volunteers and representatives, specifically Paul H. Ioanidis, from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Carmichael Running Club. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including running. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Carmichael Running Club and its affiliates including Directors, Coaches, and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY CLICKING "SUBMIT FORM" YOU ARE ACKNOWLEDGING CONSENT AND DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. IF SUBMITTING A PRINTED FORM THEN A SIGNATURE IS REQUIRED.