Southeastern Alpine Race Camp at Mt. Hood

Southeastern Alpine Race Camp at Mt. Hood

2023 Athlete Registration Form
Basic Information
Athlete Information
Athlete's Name*

First NameLast Name
Athlete Is Attending:*

Week 1Week 2
Birth Date*

MonthDayYear
2023/2024 (NEXT SEASON) Age Class*

U10 (Camp Director Approval Required)U12U14U16U18
Gender*

GirlBoyNon-Binary
Pronouns*

She/HerHe/HimThey/Them
Athlete's Home Mountain/Race Program*
'Beech Mountain, Sugar Mountain... etc.'
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
T-Shirt Size*
Adult Sizes unless otherwise specified
Swimming Ability*

Cannot SwimWeak SwimmerAverage Swimmer (can tread in place water for at least 1 minute)Strong Swimmer
Parent/Guardian Information

The first people we will contact in the event of an emergency are Parent/Guardian 1 followed by Parent/Guardian 2 unless otherwise specified in 'additional information'.
Parent/Guardian 1
Name*

First NameLast Name
Home Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
Parent/Guardian 2
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
example@example.com
Additional Parent/Guardian Information
Emergency Information

Additional Emergency Contact (optional) will be contacted if Parent/Guardian 1 and 2 cannot be reached.
Additional Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Zelle Account

If you do not have a Zelle account, please create one.
Email or Phone number connected to your Zelle Account
Equipment Verification

Athletes are required to bring Slalom protective gear for slalom training including Shinguards, Chin Guard, Pole Guards, and a FIS legal helmet. A Hard Ear FIS legal helmet is required for GS training.
This athlete has all of the required protective equipment

YesNo, but they will before campNo, and I would like assistance finding this equipment (Sara will reach out to you!)
Athlete Health Disclosure
Will the athlete be taking any medications at camp?*

NoYes, they are at least 12 years old and can administer the medication themselves.Yes, a camp representative should administer the medication for the athlete
If yes, what is the medication, dosage, and prescribed time(s) to take the medication? THIS INFO IS REQUIRED. Please report any medication they will be bringing with them including OTC allergy meds, melatonin, ibuprofen, etc. Typically they can administer these themselves, but we need to be aware that they have it.
Medication being administered by camp representatives should be turned in to the camp director immediately upon arrival.
Is the athlete allergic to any medications?*

YesNo known medication allergies
If so, which ones?
Does the athlete have any environmental allergies?*

No known allergiesYes, and they carry an EpiPenYes, but they do not carry an EpiPen
If yes, what are their allergies and what symptoms does a reaction cause?
OTC Medication Permission (Please check the medications that you are okay with camp staff administering to your child if needed)

Please request Parent Permission if any OTC mediation is needed (you can ignore the below options if you select this one)Ibuprofen (Or Children's Tylenol forBenadrylPepto Bismol or Tums
Does the Athlete have any dietary restrictions?*

No Dietary RestrictionsGluten FreeVegetarianVeganFood Allergy
If food allergy, please list foods, severity, symptoms, and if the child carries an EpiPen. If 'Other', please specify details here.
We will make reasonable accommodations for dietary restrictions, but cannot provide a different menu for each child each day. We do usually have some simple options such as grilled cheese, PB&J, etc. for those who are not able to eat the offered meal.
Has the athlete had a concussion in the last year?*

YesNo
If yes, please specify date and submit a Concussion Medical Evaluation form to the camp director via email. (No need to submit to Jeff Weinman) https://usskiandsnowboard.org/sites/default/files/files-resources/files/2019/2019%20Aug%20concussion%20release.pdf

MonthDayYear
Date
Has this athlete faced any mental health challenges in the past? (ADHD, Anxiety, Homesickness, Depression, etc)*
Regardless of how mild or severe, knowing this about our campers helps us best support them while at camp! All physical and mental health information disclosed in this form will be kept private and shared only with coaches or volunteers who need to know.
Please explain any other medical, physical, or mental health conditions/concerns here, or general health information that you think the camp staff should be aware of.
Health Insurance Information

Each athlete must have their own health insurance
Medical Insurance Provider*
Policy #*
Name of Policy Holder*
Policy Holder Date of Birth*

MonthDayYear
Date
Upload image of FRONT of Insurance Card*
Upload image of BACK of insurance Card*
Name of Primary Care Physician*
Phone Number of Primary Care Physician*
Image Release

To be completed by a parent/guardian. The image release gives us permission to use photos taken of your child on the camp instagram and Facebook, to be shared with camp parents.

I, the parent/guardian of the above listed minors hereby authorize Southeastern Alpine Race Camp to use image and video of of the above listed minors in promotional content including instagram and Facebook for the Southeastern Alpine Race Camp.
Signature*

Clear
Informed Consent and Acknowledgement (Skiing activities)

I hereby give my approval for my child’s participation in any and all activities prepared by Southeastern Alpine Race Camp at Mt. Hood during the selected camp. In case of injury to said child, I hereby waive all claims against Southeastern Alpine Race Camp at Mt. Hood (SARC) and Asheville Ski Racing and Development Team (ASCRDT) 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 basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

The named participant understands that skiing and other snow sliding and snow-play sports can be hazardous and that injuries are common. Participant accepts and assumes the risks associated with skiing, including, but not limited to: changing weather conditions, variations and steepness in terrain, snow/ice conditions, avalanches, surface or subsurface conditions, bare-spots, creeks and gullies, forest growth, rocks, stumps, course design and maintenance, terrain feature design and maintenance, the use of lifts, collisions with natural or manmade objects or other persons, defective skiing equipment, grooming and snowmobile equipment, lift towers and other structures and their components, falls, loss of control, selection of terrain, and exceeding one’s ability. Participant is the sole judge of his/her ability to negotiate any terrain or perform any maneuver whether or not directed by someone else. Participant hereby expressly assumes all risk of injury and death associated with skiing. Participant also understands that all other activities available at or through ASCRDT and SARC can be dangerous and that injuries are common. Other Activities may take place on or off ASCRD and SARC premises and include, but are not limited to, rock climbing, challenge course/zip line, trampoline, mountain biking, cliff jumping and diving, dodge ball, field sports, caving, surfing, tetherball, volleyball, disk golf, basketball, softball, ultimate Frisbee, football, soccer, swimming, canoeing, kayaking, and water park activities. Participant is the sole judge of his/her ability to participate in any other activities whether or not directed by someone else. Participant hereby expressly assumes all risk of injury and death associated
with other activities. In consideration for the use of any facilities, services, equipment, transportation, and premises, participant hereby agrees to release and indemnify, to the extent allowed by law, SARC, ASCRDT, Timberline Ski Area, and its/their owners, employees, partners, directors, officers, agents, contractors, agents, and affiliated companies from all claims by or on behalf of participant against SARC and ASCRDT arising directly or indirectly out of participant’s participation in skiing, other activities, and/or the use of any SARC and/or ASCRDT facilities, services, transportation, equipment, or premises. This release includes claims arising from any cause whatsoever, including, but not limited to negligence on the part of ASCRDT or SARC. If participant is a minor, the parent or guardian agrees to indemnify (including costs and attorney fees) ASCRDT and SARC for any claim brought on behalf of any minor named below.
Signature*

Clear
Date*

MonthDayYear
Date
Informed Consent and Acknowledgment (Non-Skiing Activities)

Non-Skiing Activities to include, but not limited to: Whitewater rafting/paddling, mountain biking, hiking, swimming, rock climbing, paddle boarding, ziplining, alpine slide, and other adventure park activities.

Waiver and release agreement please read carefully before signing. This is a release of liability and a waiver for certain legal rights.

In consideration for my being permitted to participate in the afternoon and weekend activities of Southeastern Alpine Race Camp at Mt. Hood (SARC) and Asheville Ski Racing and Development Team (ASCRDT), I agree to the following waiver and release:

I acknowledge that these activities have inherent risks, hazards, and dangers for anyone that cannot be eliminated, particularly in a wilderness environment. I understand that these risks, hazards and dangers include without limitation:
- Water hazards in boating and wading in the rivers and lakes, including drowning
- Hiking in rugged country
- Injuries from whitewater rafting and paddling equipment, and other participants
- Temperature extremes
- Inclement weather conditions and unavailability of immediate medical attention in the wilderness in case of injury
- Biking on mountain trails
- Climbing on rock
- Wildlife
I understand the risks, hazards, and dangers of these activities and have had the opportunity to discuss them with SARC and ASCRDT. I understand that these activities may require good physical conditioning and a degree of skill and knowledge. I believe I have good physical conditioning and necessary degree of skill and responsibilities. My participation in this activity is purely voluntary. No one is forcing me to participate and I elect to participate in spite of the risks. I am voluntarily using the services of SARC and ASCRDT with full knowledge of the inherent risks, hazards, and dangers involved and hereby assume and accept all risks of injury, paralysis, or death.

Lastly, I, for myself, my heirs, successors, subgrogees and executors hereby knowingly and intentionally waive and release, indemnify and hold harmless SARC and ASCRDT, their directors, officers, agents, employees, and volunteers from and against any and all claims, actions, causes of actions, liabilities, suits, expenses (including reasonable attorney's fees) which are related to, arise out of, or are in any way connected with my participation in this activity including, but not limited to, negligence of any kind or nature, whether foreseen or unforeseen, arising indirectly out of any damage, loss, injury, paralysis, or death to me or my property as a result of my engaging in these activities or the use of these services and equipment, whether such damage, loss, injury, paralysis, or death results in the form of negligence by SARC or ASCRDT or from some other cause. I, for myself, my heirs, my successors, subgrogees and executors further agree not to sue SARC or ASCRDT as a result of any injury, paralysis, or death suffered in connection with my use and participation in the whitewater rafting activities of SARC or ASCRDT.
Signature*

Clear
Date*

MonthDayYear
Date
Indemnification (if participant is under 18)

If under 18 years of age, parent, guardian, or custodian must sign the following indemnification:

In consideration for the above minor being permitted by SARC and ASCRDT to participate in the listed and non-listed activities, which include without limitation, the use of services, and equipment, I agree to the following waiver, release and indemnification:

The undersigned parent, guardian, or custodian of the above minor, for himself/herself and on behalf of said minor, hereby joins in the foregoing Waiver and Release and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend SARC and ASCRDT, their directors, officers, agents, employees, and volunteers from and against claims, actions, demands, expenses, liabilities (including reasonable attorney's fees), and negligence made or brought by said minor or by anyone on behalf of the said minor, as a result of the said minor's participation in the activities of SARC and ASCRDT and his or her use of property and facilities of SARC and ASCRDT. I, for myself and on behalf of said minor, further agree not to sue SARC or ASCRDT as a result of any injury, paralysis or death that said minor suffers in connection with his/her participation in the whitewater rafting activities with ASCRDT and SARC.
Signature of Parent, Guardian, or Custodian of Minor

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date
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 the Southeastern Alpine Race Camp at Mt. Hood and its affiliates including Directors, Coaches, and Camp Parents 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 registered camp session.

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.
Signature*

Clear
Date*

MonthDayYear
Date
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM 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.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Southeastern Alpine Race Camp at Mt. Hood

Basic Information

Zelle Account

Equipment Verification

Athlete Health Disclosure

Health Insurance Information