Owens Valley Tribal Environmental Youth Camp Application

Camper First Name *

Middle Initial *

Camper Last Name *

Age: *

D.O.B. *

Gender: *

Male

Female

Tribal Affiliation: *

Height *

Weight *

Blood Type *

Date of last Tetanus Shot *

T-shirt Size *

Physical Street Address *

Mailing Address

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Parent/Guardian Name: *

Parent/Guardian Phone Number *

Parent Email Address *

Camper Email Address *

Emergency Contact (other than parent) *

Relationship to Camper *

Phone Number *

Emergency Contact Address *

Name of Health Insurance Company *

Policy Number *

Insurance Company Address *

Insurance Company Phone Number *

Family Physician *

Physician Phone Number *

Does camper have any food or other allergies? *

Yes

No

If yes, please explain

Is camper capable of participating in strenuous activities? *

Yes

No

If no, please explain

Is camper required to take medications? *

Yes

No

If yes, please list medication

Will camper take their medication on their own? *

Yes

No

n/a

If no, do you authorize camp staff to administer medication? *

Yes

No

n/a

If camp staff is to administer medication, please provide instructions (dosage) for administration of medication and type of medication taken:

Does camper have any of the following: *

Describe other health conditions

Has camper had surgery in past 4 years? *

Yes

No

If yes, please explain

Does camper have any past injuries? *

Yes

No

If yes, please explain

May camper be given any of the following non-prescription medications under staff supervision? Check Selection(s) *

Tylenol (Acetaminophen - for headaches or elevated temperature)

Advil (Ibuprofen - for headaches or elevated temperature)

Pepto Bismol (for upset stomach)

Kaopectate (for diarrhea)

Caladryl (for skin rashes)

Benadryl (for allergies/skin rashes)

Aspirin (for headaches or elevated temperature)

None

Is camper allowed to swim at Millpond and/or Convict Lake? *

Yes at both places

No

At Millpond Only

At Convict Lake Only

Please rate camper's swimming ability. *

Can not swim

Beginner

Intermediate

Advanced

As parent or legal guardian of camper, I have completed the above application/health history/medication consent form and understand each question. I give full authorization to administer medication, if needed, as indicated above.

I hereby give permission to the Owens Valley Indian Water Commission and other personnel to administer First Aid/CPR and to arrange for medical care and treatment in case of a medical emergency. As parent or legal guardian, I also give permission to the physician selected by the Owens Valley Indian Water Commission to examine, diagnose and treat, or secure proper treatment for my child, as the physician shall determine what is proper and necessary under the circumstances. A photocopy of this authorization shall be deemed valid and accepted as the original. My child's medical condition(s) as stated above are correct and complete.

I have been informed of the nature of the Owens Valley Indian Water Commission program in which my child is enrolled. As parent or legal guardian, I understand there are risks associated with my child's participation in the camp activities and transportation to and from the camp, which pose a threat of injury, illness, or death. I am familiar with outdoor sports and activities and my child's abilities and I am not aware of any physical, emotional, or mental problem or limitation that would prevent, impair, or increase the risks involved in my child's participation at the camp. With this knowledge, as parent or legal guardian, I grant permission for my child to participate in all camp activities.

As parent or legal guardian, I authorize camp personnel to photograph and/or video record my child for promotional and documentary purposes. On behalf of myself and my child, I accept and assume the risk and full responsibility for injury, illness, death or loss of personal property or other damage, and medical or other expenses resulting from my child's presence and participation at the camp.

I hereby release and discharge the Owens Valley Indian Water Commission, its Board of Directors, staff, camp personnel, and participating tribes (Bishop Paiute Tribe, Big Pine Paiute Tribe of the Owens Valley, Bridgeport Indian Colony, Fort Independence Reservation, Utu Utu Gwaitu Paiute Tribe, Timbisha Shoshone Tribe, and any other participating Tribes) from liability to me and to my child of any and all losses, damages, expenses, and any injury to person, including death, resulting from my child's participation in the camp/program and travel to or from camp sites and activity locations.

As parent or legal guardian, I agree to direct my child to comply with all camp rules and policies and to cooperate with camp personnel. As parent or legal guardian, I understand that if my child fails to comply with the rules and policies, he/she may be expelled from the camp and sent home at my expense.

Signature *

clear

Date *

COVID-19 Exposure and Risk Authorization

An inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers for Disease Control and Prevention, senior citizens and individuals with underlying medical conditions are especially vulnerable.

Owens Valley Indian Water Commission cannot prevent you or your child from becoming exposed to, contracting, or spreading COVID-19 while participating in the youth camp. It is not possible to prevent against the presence of the disease. Therefore, if you choose to allow your child to participate in the Owens Valley Tribal Environmental Youth Camp, you may be exposing yourself and child to and/or increasing your risk of contracting or spreading COVID-19.

By attending or participating in this camp, you voluntarily assume all risks associated with exposure to COVID-19 and forever release and hold harmless Owens Valley Indian Water Commission and any participating Tribes and each of the Board of Directors, Officers, staff, and volunteers from any liability or claims including for personal injuries, death, disase or property losses, or any other loss, including but not limited to claims of negligence and give up any claims you may have to seek damages, whether known or unknown, foreseen or unforseen, in connection therewith.

We will be following the CDC guidance for the youth camp regarding face coverings and social distancing. Anyone who is fully vaccinated may choose not to wear a face covering outdoors. We ask if you or your child are not fully vaccinated that you and your child wear a face covering. All camp staff and participants will wear a face covering while inside vehicles.

As parent or legal guardian of the camper, I have read the COVID-19 Exposure and Risk Authorization above and hereby accept the risk, agree to the terms above, and give consent for my child to participate in the camp.

Signature *

clear

Date *

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Adult Small	Adult Medium	Adult Large
Adult X-Large	Adult 2x	Adult 3x
Adult 4x