Allergies / Medications: Allergies to food, Drugs, insect bites/stings*:
Any Other Medical Problems (Asthma, etc.):
Medication(s) child is taking:
The Camp Supervisor must be notified if medication is brought to camp. Prescription drugs must be in their original pharmacy containers (no modifications). In case of an emergency, please contact*:
Relationship to Child*:
I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorizes the La Cumbre Country Club coaches, assistant coaches, or any other adult acting in the capacity of supervisor, consent to medical, surgical, or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital.
Parent or Legal Guardian Signature*: Date*: Acknowledgement, Consent and Release: 1.
Acknowledgement & Consent:I understand that, in addition to planned activity, I or the Participant of whom I am the guardian may be permitted to make use of other facilities of the La Cumbre Country Club, including the swimming pool. I understand that accidents, injuries, and sometimes drowning can occur during swimming and diving activities. I personally assume all risks of personal injury which may occur during my or the Participant’s participation involvement in the Activity and in any associated or related activities, including swimming and diving activities, and specifically consent to the Participant’s use of the La Cumbre swimming pool facilities.
Please Initial: 2. Release:I hereby release La Cumbre Country Club and its officers, employees, and agents of any and all liability that may arise by reason of any injury to persons or damage to or loss of property that occurs as a result of my or the Participants involvement in the Activity and waive and agree not to assert against La Cumbre Country Club or its officers, employees, or agents any claims that may arise as a result of any such injuries or damages.
Please Initial: 3. Indemnity:I agree to indemnify and hold La Cumbre Country Club and its officers, employees, and agents free and harmless from and against any and all claims, causes of action, liabilities, damages, costs or expenses, including attorney’s fees resulting or alleged to have resulted from or to be attributable to: (a) the condition or any alleged defect in the condition of the premises and the facilities at which the Activity takes place or the manner in which such premises and facilities are cared for, kept and maintained, or (b) the actions and conduct of the employees and agents of the La Cumbre Country Club who are present when the Activity takes place.
Please Initial: 4. Voluntary Execution:I have carefully read this Acknowledgement, Release and Indemnity. I understand it to be a complete release of liability and promise not to sue or make any claim against La Cumbre Country Club officers, employees and agents for any harm, damage, or loss resulting from my involvement, or the involvement of the Participant in the Activity. I sign this acknowledgement, Consent and Release of my own free will.
Parent or Legal Guardian Signature*: Date*: