UniversityofGuam
AdventureSportsCamp 2017
Phone:(671)735-2600/1|Fax:(671)734-1233|Email:
REGISTRATIONFORM
PAID:
LOG:
ASC 2017 Registration Form Revised 3/2/2017 CT
Nameof Child:(PleasePrintorType)
(1)
FamilyName FirstName MiddleInitial Age
(2)
FamilyName First Name Middle Initial Age
(3)
FamilyName First Name Middle Initial Age
Nameof ParentorGuardian:
ContactNumber(s): EMAIL:
ASC 2017 Registration Form Revised 3/2/2017 CT
CheckOne
PLEASEINDICATEAPPROPRIATEENROLLMENTSELECTIONS
ASC 2017 Registration Form Revised 3/2/2017 CT
ASC 2017 Registration Form Revised 3/2/2017 CT
Session1:June 12-23, 2017
Session2:June 26-July 7 2017
(No camp onJuly04,2017)
Session3:July 10-21, 2017
(No Camp- July21)
Session4:July 24- August 4, 2017
Session 5:Aug7-11, 2017 (1 week only)
ASC 2017 Registration Form Revised 3/2/2017 CT
NOTE:Childrenmustbeinpropersportattire.Thecampwillnotberesponsibleforanylossesordamagestopersonalproperty.
ASC 2017 Registration Form Revised 3/2/2017 CT
REGISTRATIONFEE-$25.00USD[Non-Refundable– OneTimeFeePerChild]
RESIDENT-$250.00USD[MUSTShowProofofResidency/Does not include,TransportationFees,ExcursionFees]
RESIDENTPer ADDITIONALCHILD-$225.00USD
NON-RESIDENT-$500.00USDPerChild[Includes,Lunch,Snack,TransportationFees,ExcursionFees]
CAMPSHIRT-$10.00-ShirtSize(YouthorAdultSizes):
ASC 2017 Registration Form Revised 3/2/2017 CT
PAYMENT:CASH,CHECK,orCREDITCARDpaymentswillbeaccepted.NOTE:FullPaymentmustbereceivedPRIORtotheSTARTofeachSession.
METHODOFPAYMENT(forPIPOfficeUseOnly)
[ ]Credit Card:[ ] VISA[ ] MC[ ]Cash:$ [ ] Check No.: ;$
Cash/CheckPaymentsmaybedeliveredtotheProfessionalandInternationalProgramsofficelocatedonthe2ndFlooroftheComputerCenter/MARC
Buildingormailedto: ProfessionalandInternationalPrograms- AdventureSportsCamp
UOG Station,Mangilao,GU96923
ASC 2017 Registration Form Revised 3/2/2017 CT
ForCreditCard payments,pleasecomplete thefollowingfieldsonthecredit cardauthorizationform:Cardholder’sName,amountto becharged, card type,cardnumber,signatureand contactinformation.Completed creditcardauthorizationformsmaybedeliveredtotheProfessionaland InternationalProgramsofficelocatedonthe 2ndFloorofthe ComputerCenter/MARCBuilding,emailedto orfaxedto
+1(671)734-1233.
Physician: OfficePhone:
HEALTHINFORMATION:List anyphysicalconditionscounselorsshouldbe awareof:(i.e.,asthma,allergies, diabetes,epilepsy,medications,etc.):
INCASEOFEMERGENCY,CONTACT:
Name: Contact Number(s):
Name: Contact Number(s):
AUTHORIZEDTOPICK-UP:
Name: Contact Number(s):
Name: Contact Number(s):
Name: Contact Number(s):
STATEMENTOFRESPONSIBILITY,RELEASEANDAUTHORIZATIONTO
PARTICIPATEINUOG’SADVENTURESPORTSCAMP
By signingbelow,I acknowledge thecampparticipantlistedabove is enrolled in theAdventureSportsCampat theUniversity ofGuam(“University”),I amvoluntarily registering my child intheUOG AdventureSportsCampon the indicateddatesabove.My child’s participationin thisProgramis voluntary. In considerationof being allowed to participate inthisProgram,I hereby state and agreeto the following:
1.Bymy signaturebelow,I release andabsolve theUniversityof allresponsibilityand liability for any injuries, illnesses (includingdeath),claims, damages, charges, billsand/or expensesmy childmay incur asa result of participatingin the program.
2.I,individually,and onbehalfofmy heirs, successors, assigns and personal representatives, agree toindemnify, defend and holdharmless theUniversity and theProgramand their employees, agents, officers, trusteesandrepresentatives(in their official and individualcapacities) fromany and all liability, loss, damage or expense,includingattorney’s fees, thattheyor any ofthemincur or sustainas a resultof any claims,demands,action, damages,judgments, costs or expenses, includingattorney’s fees,whichariseoutof,occurduring,orare inanyway connectedwith in the Program.
3. I hereby acknowledge thatI haveread,understandandwill abide by eachof thetermsand conditionsof thisAgreement.
I authorizethe campdirector(s) toact forme inanyemergencyrequiring medical attention. I understandI amresponsible forall hospital,laboratory and doctor'sfees. My childisphysicallyfitto participatein vigorous physical activities. I further understandthat neithertheUniversityofGuamnor anyone associatedwith theUOG AdventureSportsCampwill be heldresponsiblefor anyaccident orillness.I alsogrant permissionto use any photos, videos,and the like for futurepromotions ofthis camp.
Signature of Parent or Guardian: Date:
ASC 2017 Registration Form Revised 3/2/2017 CT