Summer & Enrichment Camp CAR Form

I am a parent or legal guardian of...*

Camper First NameCamper Last Name

Child's Age*

Birth Date*

MonthDayYear

As Participant's parent or legal guardian, I am permitting Participant to participate in Carrollwood Day School Summer Camp and Enrichment Camp activities (the "Event"). This includes, but is not limited to, athletic activities, field trips on and off campus (if applicable), and transportation to and from said activities, if needed. I understand and agree that if Participant abuses the privilege of Carrollwood Day School’s transportation in any way due to disrespectful behavior or abuse of any vehicle or equipment, then Participant will forfeit Carrollwood Day School’s transportation. In consideration for Participant being allowed to participate in the Event, and pursuant to Section 744.301(3), Florida Statutes, if the Event is deemed or determined to be a commercial activity for purposes of Section 744.301(3), I, for myself, for Participant, and for Participant's heirs, family, personal representatives, and/or assigns (collectively, the "Releasors"), do hereby in advance release, waive, discharge, and agree not to sue Carrollwood Day School, and all of its respective partners, stockholders, officers, trustees, directors, employees, representatives, coaches, volunteers, agents, affiliates, and sponsors, collectively, the "Released Parties," from all present and future claims which would accrue to Participant for personal injury, including death, and property damage resulting from an inherent risk in the Event. I acknowledge and understand that an "inherent risk" in the Event means those dangers or conditions known or unknown, which are characteristic of, intrinsic to, or an integral part of, the Event and which are not eliminated even if the Event provider acts with due care in a reasonably prudent manner. I further acknowledge and understand that the term "inherent risk" includes, but is not limited to, (i) the failure of the Event provider to warn me or Participant of an inherent risk, and (ii) the risk that Participant or another participant in the Event may act in a negligent or intentional manner and contribute to the injury or death of Participant. Additionally, I understand that a participant does not include the Event provider or its owners, affiliates, employees, or agents. Further, in consideration for Participant being allowed to participate in the Event, and pursuant to Section 744.301(3), Florida Statutes, if the Event is deemed or determined to be a noncommercial activity for purposes of Section 744.301(3), I, for myself, for Participant, and for the other Releasors, do hereby in advance release, waive, discharge, and agree not to sue Carrollwood Day School, and the other Released Parties, from all present and future claims for property damage, personal injury, or wrongful death arising from or relating to Participant's participation in the Event to the extent permitted by common law. I understand and agree that the Released Parties are not responsible for any injury or property damage arising out of the Event, even if caused by Released Parties’ negligence, to the extent permitted by common law. *

INITIAL

It is my clear understanding that participation in competitive athletics or other activities creates a risk normally associated with such activities and may result in severe injury, including paralysis or death. I understand, and Participant understands, that Participant is voluntarily participating in the Event with knowledge of the dangers involved, and both the Participant and I agree to accept all risks of participation. I represent that I understand the nature of the Event and that Participant is qualified, in good health, and in proper physical condition to participate in such Event. I acknowledge that if I believe Event conditions are or become unsafe, I will immediately discontinue Participant's participation in the Event. I agree on behalf of myself and the other Releasors, to the extent permitted by law, to indemnify and hold harmless the Released Parties from any and all claims, actions, suits, procedures, costs, expenses, damages, and liabilities, including attorneys' fees, arising from or relating to Participant's participation in the Event and all related activities. *

INITIAL

I acknowledge that Carrollwood Day School is taking reasonable measures to prevent the transmission of COVID-19 consistent with applicable public health guidelines. I also acknowledge and recognize that it is impossible to ensure that the school and campus are 100% free of COVID-19 and that being at the school and on campus, as well as participating in the Event, contain inherent risks that cannot be eliminated regardless of the care taken to avoid the spread of COVID-19. I acknowledge, understand, and appreciate these and other risks are inherent in participating in the Event. *

INITIAL

I understand that this Consent, Authorization, and Release Form is intended to be as broad and as inclusive as permitted by the laws of the state in which the Event occurs, and agree that if any portion of this Consent, Authorization, and Release Form is deemed or determined to be invalid for any reason, the remainder of this Consent, Authorization, and Release Form will continue in full legal force and effect. I further agree that any legal proceedings related to this Consent, Authorization, and Release Form shall take place in Tampa, Florida. *

INITIAL

I hereby give permission for Carrollwood Day School's trained staff to administer appropriate medical attention to Participant including, but not limited to, first aid treatment and other services. If Participant should become ill or injured at a Carrollwood Day School function, on or off campus, I understand that the person(s) in charge will: 1) contact 911 first in any medical emergency situation; 2) contact me immediately; or 3) contact the person(s) designated if I cannot be reached. Carrollwood Day School is authorized to contact Participant’s physician and/or arrange for immediate emergency treatment. The physician or medical facility is authorized to administer emergency medical treatment necessary to the health and safety of Participant. I agree to be financially responsible for emergency medical payments and any other medical treatment payments due to services rendered to Participant in case of illness or injury. Further, I will not hold Carrollwood Day School liable for any accidents/injuries that may occur on or off campus at the Event and all related activities. *

INITIAL

I give Carrollwood Day School permission to use photographs of Participant, taken during summer (Initial) camp, enrichment camps, and off-campus trips. These photographs may be used internally and externally. I give my permission for photographs of Participant to be posted inside the classroom, in the hallways, for teacher education, and for historical record. I also give my permission for photographs of Participant to be used for publicity purposes on the school website, on the school’s social media pages, in brochures, or other means of publicity. I understand that Participant will not be identified by name when photographs are used for public purposes. *

INITIAL

Parent/Guardian Information:

Name*

First NameLast Name

Relationship*

Phone Number*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Family Physician*

First NameLast Name

Physician Phone*

Please enter a valid phone number.

Physician Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Company*

Insurance Policy Number*

Emergency Contact Information

Emergency Contact #1 Name*

First NameLast Name

Relationship*

Phone Number*

Emergency Contact #2 Name*

First NameLast Name

Relationship*

Phone Number*

Please enter a valid phone number.

Please provide us with complete and accurate medical information so Carrollwood Day School may respond appropriately in the event of an emergency. For Participant’s safety, this information will be shared with Participant’s instructor and other school officials, unless otherwise requested.

Participant is currently taking the following medications (List ALL or write "none"):*

Participant will be bringing the medications listed above with them to camp:*

YesNo

Participant suffers an allergic reaction to the following medications/substances:*

Please list ALL existing medical conditions: *

I hereby state that, to the best of my knowledge, my answers to the true and 7 . correct ) and I understand that it is my responsibility to notify the Summer Camp Coordinator and Counselors, as soon as possible, if any changes to the above information occur.*

INITIAL

By this authorization, I agree to indemnify, release and hold Carrollwood Day School harmless from any and all liability in providing treatment to Participant, and further, I grant my permission regarding the use of the above information.*

INITIAL

NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN

READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF THE RELEASED PARTIES ABOVE) (AS DEFINED USE REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGH T TO RECOVER FROM THE RELEASED PARTIES IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND THE RELEASED PARTIES HAVE THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.

TEMPORAL SCOPE: This Consent, Authorization, and Release Form shall also apply to any other activity or event that Participant participates in that i s conducted or sponsored by any of the Released Parties within one (1) year from the date on which I sign this Consent, Authorization, and Release Form below, whether or not such future activities or events are similar or identical to the Event listed abov e. I understand that the Released Parties may not require me to execute a new Consent, Authorization, and Release Form for any such future activities or events that Participant might participate in within one (1) year from the date on which I sign this Con sent, Authorization, and Release Form, and that this Consent, Authorization, and Release Form will apply with full force and effect to Participant’s participation in any future events and activities conducted or sponsored by the Released Parties within one Form is signed by me. (1) year from the date this Consent, Authorization, and Release

ACKNOWLEDGEMENT OF UNDERSTANDING: I am of legal age and am freely signing this Consent, Authorization, and Release Form on behalf of the Participant. I have read this Co nsent, Authorization, and Release Form fully, understand its terms and understand that I am giving up substantial rights. I acknowledge that I am signing the agreement freely and voluntarily, and intend my signature to be a complete and unconditional relea se of all liability to the greatest extent allowed by law

PRINT CHILD NAME:*

First NameLast Name

PRINT PARENT OR LEGAL GUARDIAN NAME:*

First NameLast Name

Date*

Date

PARENT OR LEGAL GUARDIAN SIGNATURE:*

Clear

CARROLLWOOD DAY SCHOOL