CKSF SUMMER DAY CAMP

PARTICIPANT INFORMATION
PLEASE RETURN THIS COMPLETED FORM BY JUNE 14TH. ONE FORM PER PARTICIPANT IS REQUIRED.

Child’s Name: Surname, First Name Citizenship School: Grade: Age: Gender:
(please print) Status: Male
Female

Address: Postal Code Phone _____________________ Home

Numbers _____________________ Work
_____________________Cell
Parent/Guardian’s Name (please print) Relationship to Participant Drop off/Pick Up
available?

Drop off Time: Pick up Time:

Please state any allergies, medical conditions, or medications that we should be aware of.
(Please keep in mind that this camp may involve intense physical activity)

WAIVER AND RELEASE

I, ____________________, HEREBY WAIVE AND RELEASE CKSF and CKSF Youth Committee from liability pertaining to the
matters set forth below. I understand that by signing this Waiver and Release, I expressly and willingly agree to assume complete
responsibility for any risk of injury that may arise from the Summer Day Camp as stated in the assumption of risks. On behalf of
myself, my heirs, assigns and next of kin, I waive all claims for damages, injuries, and death sustained to me or my property, that I
may have against the abovenamed Released Party relating to such activity. I understand that the activities that my child will
participate in have potential for injuries, damage to personal property, and/or death. By this waiver, I assume any risk, and take
full responsibility and waive any and all claims of personal injury, including physical injury, damage to personal property, and death
relating to all activities associated with this Summer camp. If my child is injured from said activity, I will not hold Released Party
responsible even if the injuries were caused by negligence on my part or the Released Party, or any other party under or affiliated
with the abovenamed Released Party. I also understand that CKSF and CKSF Youth Committee do not have liability insurance.

Assumption of Risks
In consideration of my child’s participation in the Summer Day Camp, I acknowledge that I am aware of the possible risks, dangers
and hazards associated with my child’s participation in the Summer Day Camp, (including the possible risk of severe or fatal
injury to my child or others). These risks include but are not limited to the following:
a) the risks associated with travel to and from locations to be visited during the Summer Day Camp, including transportation
provided by commercial, private, and/or public motor vehicles;
b) the possibility of bodily injury (broken bones and soft tissue damage) including dental damages from falling down, injuries
incurred while getting on or off (in or out of) the mode of transportation being used for the event, being knocked down or
being involved in a physical confrontation whether caused by my child, or someone else

I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS WAIVER AND RELEASE. I UNDERSTAND AND CONFIRM THAT
BY SIGNING THIS WAIVER AND RELEASE I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS. I HAVE SIGNED
THIS WAIVER FREELY, VOLUNTARILY, UNDER NO DURESS OR THREAT OF DURESS, WITHOUT INDUCEMENT,
PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. MY SIGNATURE IS PROOF OF MY INTENTION TO EXECUTE
A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. I AM
18 YEARS OF AGE OR OLDER AND THE PARENT/GUARDIAN OF THIS CHILD, AND MENTALLY COMPETENT TO ENTER
GRANT THIS WAIVER.

Signed this on _____ day of _____________________, 2010, at Calgary, Alberta.

Forms may be returned to the following address:

Dr. Ki-Young Lee

Rm# 359, HMRB
Dept. of Cell Biology and Anatomy
The University of Calgary
3330 Hospital Dr. N.W.
Calgary, AB. T2N 4N1