Elmcitysquash.com

ELM CITY SQUASH
EMERGENCY CONTACT INFORMATION
PLEASE ATTACH A COPY OF THE FRONT AND BACK OF YOUR HEALTH INSURANCE CARD
Participant’s First and Last Name: _______________________________________ Address: _____________________________________________________________________ Health Insurance Provider: _______________________________________________________ Contact Number of Health Insurance Provider: ______________________________________ Allergies and other health concerns/medication use (e.g. Asthma – use of Flovent or recent recovery from sprained ankle): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Elm City Squash Activity Name: ______________________ Emergency Contact (1) First and Last Name: ________________________________________ Best Contact Number : _______________________ Alternate Contact Number : _____________________ and ______________________________ Emergency Contact (2) First and Last Name: _________________________________________ Best Contact Number: _____________________ Alternate Contact Numbers: _____________________ and ___________________ The following additional people are authorized to pick up my child from Elm City Squash: Name: ____________________________ Contact # 1: ____________ Contact # 2: ______________ Name: ____________________________ Contact #1: _____________ Contact # 2: ______________ PHOTOGRAPHY RELEASE
I give permission to Elm City Squash to take photographs and video my son/daughter ________________________________ during Elm City Squash activities. These images can be used on the website and in brochures for Elm City Advertising. All videos will only be used for teaching purposes and will not be for public viewing. _________________________ ____________________________ OFF-SITE ACTIVITIES FORM
Participant’s Name:_____________________________________ Name of Parent/Guardian:__________________________________________________ By signing this form, I ___________________ am giving Elm City Squash permission to take my son/daughter____________________________ to off-site recreational activities while attending Elm City Squash as long as Elm City Squash staff accompany all travel and activities. Signature of Parent/Guardian____________________________ Date:______________ YALE UNIVERSITY
PARTICIPANT HOLD HARMLESS AND
ASSUMPTION OF RISK AGREEMENT
***READ BEFORE SIGNING***
Participant Name: ____________________ Age: ______________________ In consideration of being allowed to participate in any way in _______________________ (Camp) related events and activities (the “Program”), I, the undersigned, acknowledge, appreciate and agree that: 1. The inherent risk of injury from the activities involved in the Program can be significant, including the potential for permanent paralysis and death. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, and assume full responsibility for my participation and; 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately and; 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Yale University and each of its officers, officials, agents, and/or employees (collectively, “Releasees”) from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, arising out of or in connection with my participation in the Program, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Participant Signature: ____________________________ Date : _____________________ For parents/guardians of a participant of minor age (under age 18 at time of registration) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incident to my minor child’s involvement or participation in the Program as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Parent/Guardian Name: ____________________________ (Please Print) Emergency Phone Number(s) : ________________________________ Parent/Guardian Signature: _______________________ Date: ____________________________ ELM CITY SQUASH
PARTICIPANT HOLD HARMLESS AND
ASSUMPTION OF RISK AGREEMENT
***READ BEFORE SIGNING***
Participant Name: ____________________ Age: ______________________ In consideration of being allowed to participate in any way in _______________________ (Camp) related events and activities (the “Program”), I, the undersigned, acknowledge, appreciate and agree that: 1. The inherent risk of injury from the activities involved in the Program can be significant, including the potential for permanent paralysis and death. While particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, and assume full responsibility for my participation and; 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately and; 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Elm City Squash and each of its officers, officials, agents, and/or employees (collectively, “Releasees”) from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, arising out of or in connection with my participation in the Program, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Participant Signature: ____________________________ Date : _____________________ For parents/guardians of a participant of minor age (under age 18 at time of registration) This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incident to my minor child’s involvement or participation in the Program as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law. Parent/Guardian Name: ____________________________ (Please Print) Emergency Phone Number(s) : ________________________________ Parent/Guardian Signature: _______________________ Date: ____________________________ ELM CITY SQUASH CODE OF CONDUCT
I agree that I will wear goggles at all times when I am playing squash. If I play with without goggles at any time I fully responsible for any injury. • I agree that I will respect every member of the coaching staff and activity group and treat everyone the way that I • I will respect the squash facility by wearing the correct footwear, picking up after myself, and keeping my gear in • I WILL NOT LEAVE THE SQUASH FACILITY, HOTEL, OR ANY OTHER PLACE WITHOUT A STAFF • While I am enrolled in Elm City Squash I am aware that I am an ambassador of my program and will be behave in a fitting manner at all times. This includes my behavior in a hotel. • I agree that any use of alcohol, tobacco, or other banned substances will result in my immediate expulsion from I understand that if I do not comply with the above Code of Conduct, my parents can be called and I can be asked to leave Elm City Squash activities without reimbursement. SIGNATURE OF PLAYER: ________________________ DATE______________ SIGNATURE OF PARENT/GUARDIAN: _________________________________ DATE_____________

Source: https://elmcitysquash.com/docs/EMERGENCY%20CONTACT%20INFORMATION%202014.pdf