2.  Waiver of Liability, Assumption of Risk, and Indemnity Agreement

                                           3.  Authorization to Consent of Treatment of Minor

                                           4.  2009 CAL Camps Physician Form (MUST be signed by a Physician)

                                           5.  Cal Coaches Camp Medication Form

Below is an EXAMPLE of the required forms.  Official forms MUST be used.

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Must submit a separate application, waiver and treat & transport form for each participant.

PLEASE PRINT CLEARLY - Incomplete or illegible forms will not be processed.

Please submit this form by Mail or Delivery, payment must be submitted at time of enrollment.

ENROLL ONLINE NOW! www.calbears.com/camps

Participant Contact Information

Participants Name___________________________________________Birth Date / /

                                                 Last First M.I.

Address City St Zip

Parent/Contact Phone (    ) -

First Last

School Grade in Sept. 2009 HS Grad Year

How did you hear about these camps?

Parent/Contact E-Mail (REQUIRED)

(Enrollment confirmation will be sent to this e-mail address)

Emergency/Medical Information (REQUIRED)

Alternate Emergency Contact Phone (    ) -

(Must be different from Parent/Contact Name) Last First

Doctor Information Phone (    ) -

Name

Medical Insurance

Company Policy # Exp. Date Policy Holder’s Name

Medical, Physical or Emotional Conditions (including allergies and disabilities)? _ Yes _ No

If Yes, please provide information to assist us:

Medications: _ Yes _ No List Medications (including inhalers):

Is your child up-to-date on all state-required Immunizations? _ Yes _ No

If No, please explain:

Please list any other health information relevant to camp participation

Camp Selection (All Camps Are For Athletes Entering Grades 9-12)

INDIVIDUAL CAMP: June 13-15

_ Overnight Camp $335 _ Day Camp $265

TEAM CAMP: June 19-21

Overnight Camp: _ $335 (1-19 Campers) _ $320 (20-40) _ $305 (41+)

Day Camp: _ $265 (1-29 Campers) _ $255 (30+)

KICKING CAMP: June 26-28

_ Overnight Camp $475 _ Day Camp $375

_ Additional BBQ Tickets: (Qty. _____ @ $7/Each) Total: ________

Level of Competition Next Season _Frosh _JV _Varsity

Position ___________ Height ________ Weight _______ Yrs. Exp. _____

Roommate Request __________________________________________

(Please list only one roommate request, we cannot accommodate several requests)

Payment Total: Make Checks Payable to “UC Regents” Check #

Mail or Deliver completed enrollment form, waivers and payment to:

Cal Athletic Ticket Office Attn: CAL Football Camp 2223 Fulton Street, 1st Floor Berkeley, CA 94720-4422

Phone: (510) 642-3277 Fax: (510) 642-1765 E-Mail: calcamps@berkeley.edu

NCAA RESTRICTION - Due to NCAA restrictions, institutional staff members or representatives of its athletics interests shall not employ or give free or reduced admission privileges to a high school, preparatory school or two-year college athletics award winner.

NONDISCRIMINATION STATEMENT - In accordance with applicable Federal laws and University policy, the University of California does not discriminate in any of its policies, procedures, or practices on the basis of race, color, national origin, sex, sexual orientation, age or handicap.

REFUND POLICY - Requests for refunds or transfers must be submitted in writing (via e-mail, letter or fax) we cannot accept requests by phone. Requests must be received no less than 30 days prior to the first day of camp to qualify for a refund or transfer. Request for refunds or transfers received prior to 30 days before the first day of camp will be processed and assessed a fee. No refunds or transfers are issued for requests received later than 30 days before the start of camp. Camps are not prorated and participant substitutions are not allowed. No

refunds are given to campers dismissed from camp for inappropriate behavior.

Participant’s Name (Last, First): __________________________ Camp: _________________________

*A separate waiver is needed for each participant per camp.

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UNIVERSITY OF CALIFORNIA, BERKELEY

CAL Athletic Camps

Waiver of Liability, Assumption of Risk, and Indemnity Agreement

Waiver: In consideration of being permitted to participate in any way in the Cal Athletic Youth Programs that I

have enrolled my child in, as listed on the Registration Form; hereinafter called "The Activity", I, for myself,

my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue

The Regents of the University of California, its officers, employees, and agents from liability from any and all

claims including the negligence of The Regents of the University of California, its officers, employees and

agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but

not limited to, participation in The Activity.

________________________________________ ___________________________________________

Signature of Parent/Guardian of Minor           Date               Signature of Participant                        Date

Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be

eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but

the risks range from 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury

or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including

paralysis and death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks

that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly

assume all such risks.

Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD The Regents of the

University of California HARMLESS from any and all claims, actions, suits, procedures, costs, expenses,

damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to

reimburse them for any such expenses incurred.

Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks

agreement is intended to be as broad and inclusive as is permitted by the law of the State of California and that

if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal

force and effect.

Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity

agreement, fully understand its terms, and understand that I am giving up substantial rights, including my

right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my

signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.

________________________________________ _____________________________________________

Signature of Parent/Guardian of Minor          Date                    Signature of Participant               Date

Participant's Age (if minor) _____ Vol Waiver 7/01

Participant’s Name (Last, First): __________________________ Camp:________________________

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AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

(I) (We), the undersigned parent(s)/guardian(s) of __________________________________, a minor, do

hereby authorize University of California, Berkeley Health Services or attending medical personnel as agent(s)

for the undersigned to consent to any X-ray examinations, anesthetic, medical or surgical diagnosis or

treatment, or hospital care which is deemed advisable by, and is to be rendered under the general or special

supervision of, any physician and/or surgeon licensed under the provisions of the Medical Practices Act,

California Business and Professions Code §2000 et. seq.; or any X-ray examination, anesthetic, dental or

surgical diagnosis or treatment, or hospital care which is deemed advisable by, and is to be rendered under the

general or special supervision of, any dentist licensed under the provisions of the Dental Practices Act,

California Business and Professions Code §1600 et. seq.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care

to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such

diagnosis, treatment or hospital care which aforementioned physician or dentist, in the exercise of his/her best

judgment, may deem advisable. This authorization is given pursuant to the provisions of California Family

Code §6910.

(I) (We) hereby authorize any hospital, which has provided treatment to the above-named minor pursuant to the

provisions of California Family Code §6910, to surrender physical custody of such minor to (my) (our) above

named agent(s) upon the completion of treatment. This authorization is given pursuant to California Health and

Safety Code §1283

These authorizations shall remain effective until December 31, 2009, unless sooner revoked in writing

delivered to said agent(s).

__________________________________________________________________________________________

Signature of Parent/Guardian of Minor                     Date

CAL ATHLETIC YOUTH PROGRAM PARTICIPANT AGREEMENT

· This health history is correct so far as I know, and my son/daughter has permission to engage in all

prescribed camp activities, except as noted by me. My son/daughter is in good health.

· I understand that I am required to have accidental medical coverage for the child listed on this application,

and I verify that the information provided on this form is accurate and true. I understand and agree that if I

do not have accidental medical coverage for the child listed on this application, I will be financially

responsible for all charges and fees incurred in the rendering of said treatment

· I understand that at the discretion of camp/program supervisor and/or staff my child may be dismissed from

the camp/program, without refund, for inappropriate behavior.

· I understand that at the conclusion of the scheduled camp/program time, Cal Athletic Youth Programs are

no longer responsible for my child.

· I give permission to use, reprint, and produce any photographs or videos taken of me or my child and

written materials supplied by me or my child in the form of evaluations during the Cal Athletic Youth

Programs. I understand that such material will be used for university marketing purposes only.

_________________________________________ __________________________________________

Signature of Parent/Guardian of Minor    Date             Signature of Participant (18 years of older)   Date

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Participant’s Name: ___________________________

………………………………………(Last) (First)

Please Indicate Camp(s) that this form is for: (If the camp you are attending does

not appear below, you do not need to complete this form.)

Football

_Individual Camp (June 13-15)

_Team Camp (June 19-21)

_Kicking Camp (June 26-28)

Strength & Conditioning

_Session Dates: _________________

Girl’s Soccer Residential/Academy Camps

_Juniors (July 12-16)

_High School (July 12-16)

Boy’s Soccer Residential/Academy Camps

_Juniors: Session I (June 28-July 2)

_Juniors: Session II (July 19-23)

_High School: Session I (June 28-July 1)

_High School: Session II (July 19-22)

This Physician Statement MUST be signed by a Physician prior to submitting it

to the University of California. In lieu of this statement, we will accept an official

record of any physical performed within the last year, as long as it is signed by a

Physician and does not indicate any restrictions, such as indicating that the

Physician is only certifying participation in a non-contact sport. Participants will

not be allowed to participate unless the Physician Statement is complete or the

alternate record of the physical is acceptable.

I certify that_______________________________is in good health and physically able

                           (P a r t i c i p a n t s N a m e )

to take part in the camp(s) indicated above.

PLEASE PRINT LEGIBLY

Physician Name: ______________________________Phone: ___________________

Address: ______________________ City: ____________ State: _____ Zip: ________

Physician Signature: _____________________________________ Date: __________

Please indicate any health conditions that the patient has that we should know about

concerning their participation in this camp.

Return By Mail, Fax or Delivery To:

Cal Athletic Ticket Office

Attn: CAL Athletic Camps

2223 Fulton St. 1st Floor

Berkeley, CA 94720-4422

FAX TO: (510) 642-1765

Questions?

E-Mail us at: calcamps@berkeley.edu

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Cal Coaches Camp Medication Form

Return completed form to your camp Health Care Coordinator

Name of Camper _____________________________________ Date of Birth

                                          (last) (first)

Camp

FORM MUST BE COMPLETED BEFORE ANY MEDICATION IS BROUGHT TO CAMP

This form must be completed for prescribed and non-prescribed medications by the parent/guardian the physician (for prescription medication) and contain proper signatures before any medication can be administered at camp. All medications, whether prescribed or non-prescribed, are kept in the camp office. If your physician would like your child to carry either an asthma inhaler or emergency medication (i.e. Epipen or Inhaler), PART 3 must be completed by the doctor, parent, and child.

_________________________________________________________________________________________

PART 1: PARENT/GUARDIAN: Both prescribed and non-prescribed medications will be administered by authorized camp personnel in the manner and dosage given. By signing below I hereby request that authorized personnel assist this camper in taking the medication in the manner and dosage given. I understand all medications must be in their original container.

X

Parent/Guardian Signature Printed Name/Relationship Date

(    )                                           (     )

Main contact phone Alternate contact phone

PART 2: PHYSICIAN (Signature not needed if non-prescription medication) IF REQUIRED by Camp

Name of Medication Form Dose

(liquid, tabs, inhaler, etc.)

Schedule of Doses Date to Stop Medication

Restrictions, Cautions, Side Effects

X

Physician Signature Printed Name Date

Physician Phone # ( ) Address

PART 3: PERMISSION TO CARRY ASTHMA INHALERS/EPIPENS (Part I & II Must be completed)

TO BE COMPLETED BY THE PHYSICIAN: The above-named camper has been instructed in the proper use of their asthma inhaler/emergency medication. The child’s well-being is in jeopardy unless this medication is carried on his/her person. Therefore, I request that he/she be permitted to carry the asthma inhaler/emergency medication at camp. He/she understands the purpose, appropriate method, and frequency of use of asthma inhaler/emergency medication.

X

Physician Signature Printed Name Date

TO BE COMPLETED BY THE PARENT/GUARDIAN: I permit my child to carry the above-listed asthma

inhaler/emergency medication as ordered by his/her physician.

X

Parent/Guardian Signature Printed Name Date

TO BE COMPLETED BY THE CAMPER: I have been instructed in the proper use of my medication and will take

it as prescribed to mm by my physician.

X

Camper Signature Printed Name Date

PART 4: CAMP DIRECTOR (to be completed by Health Care Coordinator/designated camp staff)

Person(s) designated by camp Health Care Coordinator to assist camper in taking medication above

X

Signature of Camp Health Care Coordinator or designated camp staff Date

This information to be used by Camp Director and authorized personnel only.