Sunday Islamic School
2725 S. White Road, San Jose, CA95148 Phone: (408) 238-9496
CAMPING TRIPREGISTRATION FORM (JULY 25-27, 2003)
Print and take a copy of this form with you on your trip. Also leave a copy at home with a friend or relative.
Personal Information
Full name / Gender / __Male __FemaleNickname / Total # of people / Age
Home address
Home phone
Cellular phone
Emergency Contact Information
Name of Contact / Phone #Family Doctor / Phone #
Medical Information
Medical conditionsAllergies
Current medications
Please include Name, Age,Genderand special conditionsof ALL family members accompanying you on the back of this form. (Submit form with $55 per 18 years and above, $45 per 6 - 17years).
Waiver:
I acknowledge that our participation in some low risk activities such as taking a scenic tour day excursions, hiking, camping, sports and low challenge course events entails known and unanticipated risks which could result in physical or emotional injury, to us. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. Also, any swimming/water related activities in the river would be at our own risk.
In consideration of people named on this form being permitted to participate in such activities and to use equipment and facilities, I agree to indemnify and hold harmless MAB personnel and participants from any and all claims, demands, or causes of action which are brought by myself, and/or the minor and/or on behalf of the Minor, which are in any way connected with such use or participation by us. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
I hereby represent that the named peopleare in good health, that there are no special problems associated with the care of the individuals, and that I have adequately informed MAB personnel of any special instructions regarding the individuals. I certify that I have adequate insurance to cover any injury or damage the individual may suffer while participating, or else I agree to bear the costs of such injury or damage myself.
I authorize MAB personnel to call for medical care for the individual or to transport the individual to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed by the individual. I further authorize appropriate personnel to render such medical treatment as is necessary for the health of the individual, in their professional opinion. I agree that once the individual is in the care of medical personnel or a medical facility, MAB personnel shall have no further responsibility for the individual and I agree to pay all costs associated with such medical care and transportation.
Guardian's Signature:______Participant's Signature:______