2nd Group forms [UCP]

UCP STUDENT HEALTH RECORDS
PLEASE NOTE: THE PARTICIPANT'S HEALTH RECORDS/PHYSICIAN'S REPORT FORMS ARE DUE PER COURSE. THIS PAGE IS TO BE COMPLETED BY THE PARENT/GUARDIAN IF PARTICIPANT IS UNDER THE AGE OF 18.
Name of Participant:  First Name*   Last Name*
Date of Birth:Your birth date (MM-DD-YYYY)* Course/Program: Name of course/program*
Gender: Male   Female *
Housing: Boarding   Non- boarding*
Participant's Cell Phone: Country code (e.g., +1, +44)*    Your mobile number*     Address: Street Address*      City where you reside*   State or province*   ZIP or postal code*   *
Does the student/participant have any known allergies to food/medicine/other?   No   Yes*  ,allergies are: please list (if any):
What treatment should be given in the event of an allergic reaction?
Has student/participant ever had to use an Epi-Pen?  No   Yes*
Does student/participant carry an Epi-Pen?   No   Yes*
01) Diabetes Type:Diabetes Type   Date:   Diabetes Diagnosis Date   Yes   No*
02) Asthma/Bronchitis Comments:   Asthma Bronchitis Comments   Date:   Asthma Bronchitis Diagnosis Date   Yes   No*
03) Does the student cough, wheeze, or have trouble breathing during or after activity? Date:   Date Yes   No*
04) Epilepsy/Seizure Disorder Comments: Date:Date
Yes   No*
05) Has the student ever had a diagnosed concussion? Date:Date
Yes No*
a. If YES, how many? Concussion Count
b. Within last 6 months, provide documentation of event and include doctor's clearance.
06) Has the student ever experienced unconsciousness, memory loss or had a seizure as a result of Date:   Date   Yes   No*   a head injury?
07) Mononucleosis Comments:   Mononucleosis Comments   Date:   Date   Yes   No*
08) Has the student or any family member ever had an adverse reaction to anesthesia (ex.
malignant hyperthermia)? Date:   Date   Yes   No*
09) Does the student have a history of or currently have an eating disorder?
Date:   Date   Yes   No*
10) Does the student have a history of or currently have any mental health issues (ex. depression, anxiety, stress, ADD/ADHD)? Date: Date   Yes   No*
a. Does the student take medication related to a mental health issue? (ex. anti- depressant, antianxiety, ADD/ADHD medications)? Date: Date   Yes   No*
b. If YES, what medications?   Mental Health Medication Details
11) Has the student ever been referred/evaluated by a psychiatrist/psychologist?
Date:   Date   Yes   No*
12) Pneumonia Comments: Pneumonia Comments Date: Date   Yes   No*
13) Sinusitis Comments: Sinusitis Comments Date:Date   Yes   No*
14) Tonsillitis Comments:Tonsillitis Comments Date:   Date    Yes   No*
15) Does the student have painful menstrual cycles? How is it treated?  Painful Menstrual Cycles
Date:   Date   Yes   No*
16) Does the student have any current skin problems (ex. itching, rashes, acne, warts, and fungus)?   Date:   Date   Yes   No*
17) Does the student have frequent or severe headaches or migraines?
Date:   Date   Yes   No*
18) Has the student ever had numbness or tingling in their arms, hands, legs, or feet?
Date:   Date   Yes   No*
19) IMMUNIZATION RECORD:  Please provide a complete list of immunizations and dates that immunizations were received for the student. This record must be submitted in English for student under the age of 16
Explain “YES” Answers:   Explain
HEALTH HISTORY:
*** If student/participant has a chronic medical condition such as diabetes, seizure disorder, hemophilia, severe allergies or mental health disorder, there might be special requirements that are applicable for student/participant to attend or to board at Up Close and Personal Group (UCP). Please contact contact@ucp-group.com to discuss these requirements prior to enrolling or making any travel arrangements UCP Group In some instances, the student/participant may be required to be a non-boarding student to participate in our programs.**
Name of Participant:*
THIS PAGE IS TO BE COMPLETED BY THE PARENT/GUARDIAN

List any surgeries or hospitalizations:

	DATE	SURGERY	HOSPITALIZATION
1
2
3

CURRENT MEDICATIONS:

Please list all medications and their dosages (including over-the-counter medications and supplements) that your child is taking:

	MEDICATION	DOSAGE	INSTRUCTIONS
1
2
3
4

MEDICATION REQUIREMENTS:

1. For the safety of all of our participants, medication is not allowed to be in a participant's room.
2. No medical planners (weekly pill dispensers) are allowed.
3. All prescription medications must have an official pharmacy label attached to the bottle/package (in English) which includes the participant's name, instructions, etc. -OR- must be in its original package and accompanied by a doctor’s written orders for administration (in English).
Note: Prescription medications will be dispensed according to the pharmacy label or the doctor’s written orders only. Any changes to the dosage amount, frequency, etc. need to have a new doctor’s written order stating how it should be given.
4. All over-the-counter medications must be in their original bottle/package (in English). A parent may include specific instructions regarding how much, how often and what time your child should take it. Otherwise, it will be dispensed when participant asks for it (as needed – and per package instructions).
5. If participant carries an Epi-Pen, we strongly recommend that an extra Epi-Pen be dropped off at Health Services at check-in. Health Services can provide your child with an Epi-Pen tag for his/her sport bag.
ORTHOPEDIC HISTORY:

Please provide any previous injuries student/participant has suffered: Include dates, surgeries, and special tests (CAT scan, x-ray, MRI, etc.), right or left body part.*

	Enter injuries Note: If none please enter "NONE"
Head (Including ear, teeth, nose, and eyes):
Neck:
Back:
Chest:
Shoulders:
Arms:
Elbows:
Wrists:
Hands/Fingers:
Thighs:
Knee:
Lower Leg (shin/calves):
Ankles:
Feet/Toes:

Is there anything else we should be aware of regarding student/participant’s health?*
I hereby state, to the best of my knowledge, my answers to the above questions are complete and correct. I understand and acknowledge that I am hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic tests as electrocardiogram (EKG), echocardiogram (ECHO) and/or cardio stress test. If any of the above tests are performed on your student, please include a copy with this form.

I hereby confirm that I have valid medical insurance, and Up Close and Personal Group, and its associates, partners and contractors are not liable for any medical coverage during the period of the training.
Name of Participant (Print full name):   Full legal name of the student*

Signature:   Student signature* Date:   Date of agreement (MM-DD-YYYY)*

Who is signing this form?
I am the participant signing this form   I am the parent/guardian (for participants under 18 years of age)*

UCP CORONA VIRUS WAIVER
Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies, recommend social distancing and have, in many locations, prohibited the congregation of groups of people. Wearing mask is mandatory at all times inside academy and on training.

Up Close and Personal Group, associates and affiliates have put in place preventative measures to reduce the spread of COVID-19; however, Up Close and Personal Group, associates and affiliates cannot guarantee that you will not become infected with COVID-19. Further, attending the courses and training could increase your risk and risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19, including any existing or emerging variants/strains, by attending the course and training and being around other student, staff and instructors, and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the training may result from many reasons, including but not limited to the actions, omissions, or negligence of myself and others, including, but not limited to, employees, staff, instructors, and course participants and instructors.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with other students or attendance at the training or participation in programming (“Claims”). On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless Up Close and Personal Group, associates and affiliates, staff, volunteers, private contractor, employees, students, instructors, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Up Close and Personal Group, its employees, students, instructors’ students, staff, volunteers, private contractors, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any training or courses or program.
Print Name:   Full legal name of the student*
Signature:   Student signature*
Date:   Date of agreement (MM-DD-YYYY)*

Witness Name:   First Name   Last Name
Signature:   Signature
Date:   Date

UCP CONSENT FORM
DRUG AND ALCOHOL TESTING AUTHORIZATION

The use of illegal drugs, controlled substances and alcohol can have a detrimental impact on behavior, interfere with academic and athletic performance, cause permanent physical and mental harm to the user and increase the risk of injury to teammates, participants opponents and all others with whom the user interacts. Therefore, Up Close and Personal Group has implemented a Drug and Alcohol Testing Policy (“Policy”) that is described in the Student Handbook. All parties signing this form acknowledge that they have received, read and understand the Policy, and also understand that penalties may be imposed, including expulsion, for violating the Policy. Further, all parties signing this form agree to all of the terms, conditions and rules of the Policy.

A participant who is age 13 and older will be subject to mandatory random testing during the course. Reasonable suspicion testing may be conducted for all participants regardless of age. Each test will consist of hair analysis, urine analysis or other method adopted by Up Close and Personal Group and/ or Associates.

I hereby consent to having samples of participant's hair, urine or other body sample tested for the presence of drugs, alcohol or other substances covered by the Policy at such times as tests are required under the Policy. I also authorize the release of information concerning the results of such test to the Participant and Up Close and Personal Group.

PROPERTY DAMAGE

The Participant and his/her Parents/Guardians agree to and herby authorize a charge by Up Close and Personal Group against the credit card on file whenever necessary to cover costs of any property damages caused by the Participant to his/her room or any other facility used at or by Up Close and Personal Group.

MEDICAL IDENTIFICATION CARD

I voluntarily wish to add the following information regarding severe allergies, chronic illnesses or other potentially life threatening medical conditions to participant’s campus identification. I further consent to this information being posted on participant records and files, in print and electronically. I understand that this information is shared among Up Close and Personal Group employees and/or associates.
OFF CAMPUS ACTIVITIES (PLEASE CHOOSE ONE BELOW):

Participant has permission to participate in all off-campus supervised activities. Participant does not have permission to participate in any off-campus supervised activities* .
Comments:
Name of Participant (Print full name):   Full legal name of the student* Course/Program:Name of course/program*

Signature:   Student signature* Date:   Date of agreement (MM-DD-YYYY)*

Who is signing this form?
I am the participant signing this form   I am the parent/guardian (for participants under 18 years of age)*

UCP RELEASE FORM
WHEREAS, in return for use of premises and any property or facility public or private that Up Close and Personal Group, its associates and its affiliates choose and equipment, instruction in firearms, & for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Undersigned agrees to the following: To indemnify, hold harmless and defend UCP Group Inc. and any of its associates and/or affiliates any of its employees, instructors, directors, officers or agents from any and all fault, liabilities, costs, expenses, claims, demands or lawsuits arising out of, related to or connected with the instruction in or discharge of firearms; the Undersigned’s participation in discharging firearms; observing the discharging of firearms, the range, buildings, land and premises Any property or facility public or private that Up Close and Personal Group, its associates and its affiliates choose used (the “Premises”); the Undersigned’s presence on or use of Premises Any property or facility public or private that Up Close and Personal Group, its associates and its affiliates choose; and any and all acts or omissions of the Undersigned. Should any such claim, demand or lawsuit arise or be asserted in any way related thereto, whether arising under the laws of the United States, the State of California or any other State, or under any theory of law or equity, the Undersigned will indemnify, hold harmless and defend UCP Group Inc. and any of its associates and/or affiliates, from any and all costs, expenses or liability including, but not limited to, the cost of any settlement or judgment made or rendered against UCP Group Inc. and any of its associates and/or affiliates, whether individually, jointly, or in concert with the Undersigned, together with all costs of court and other costs or expenses incurred in connection with any such claim, demand or lawsuit, including attorney’s fees. The Undersigned waives any and all rights and claims for damages, losses, demands and any other actions, which exist or which may arise UCP Group Inc. and any of its associates and/or affiliates, (including, but not limited to any and all injuries, damages or illnesses suffered by the Undersigned or the Undersigned’s property), which may, in any way whatsoever, arise out of, be related to or be connected with: discharging firearms, the Premises, including any latent defect in the Premises; the Undersigned’s presence on or use of Premises; the Undersigned’s property (whether or not entrusted to UCP Group Inc. and any of its associates and/or affiliates); UCP Group Inc. and any of its associates and/or affiliates and any of its associates and/or affiliates, shall not be liable for, and the Undersigned, hereby expressly releases UCP Group Inc. and any of its associates and/or affiliates from any and all such claims. This waiver is both personal and on behalf of any minor for whom it is executed. Persons under the age of 18 must have a parent or guardian present during class and sign this waiver. The Undersigned hereby expressly assumes the risk of entering the Premises and taking part in activities on the Premises which include but are not limited to the discharge of firearms and the firing of live ammunition; or observing individuals discharging firearms; & the use of the facilities.
The Undersigned furthermore hereby acknowledges and agrees that he/she has read, understands and will at all times abide by all UCP Group Inc. and any of its associates and/or affiliates rules, instructions, procedures, safety rules, and any and all Range Safety Officer instructions, whether communicated in writing, posted on the premises & communicated verbally. This instrument binds the Undersigned and his/her executors, administrators, assignees or heirs and any minor for whom it is signed. By signing this waiver I also confirm and attest; that I am not a convicted felon, or under indictment in any court for a crime punishable by imprisonment for a term exceeding one year, I am not a fugitive from justice, I do not use or addicted to any unlawful controlled substances, I have not been adjudicated as a mental defective or have been committed to any mental institution, I am not an illegal alien, have not been discharged from the military under dishonourable conditions, have not renounced my United States citizenship, am not subject to a court order restraining me from harassing, stalking, or threatening an intimate partner or child of the intimate partner, and have never been convicted of a misdemeanour crime of domestic violence.
I also further attest to the fact I am not currently under the influence of any substances that may hinder or impede my actions in handling a firearm safely for the intended purposes of this course. I hereby authorize the use, publication, and reproduction by UCP Group Inc. and any of its associates and/or affiliates of any photographs taken of me for any editorial use, advertising, promotion, and hereby waive all claims or rights arising out of such use, publication or reproduction. I also waive any right to inspect or approve the finished materials in which such photographs will be used.
Name of Participant (Print full name):   Full legal name of the student*

Signature:   Participant’s signature* Date:   Date of signing*

Who is signing this form?
Signed by Participant   Signed by Parent/Guardian of participant (if participant is under 18 years of age) *

RANGE & HOSTILE ENVIRONMENT TERMS
This policy covers the terms and conditions of the training/instructor, classroom and range and accommodation/academy including other participants, the local authorities and the general public.

To be considered as a rule of general politeness and safety and consideration to others. The terms and conditions below must be adhered to and once signed you have accepted them in their full entirety
- Rules of the range; no phones on the range except the Range Safety Officer (RSO) and Chief Range Safety Officer (CRSO).
- Basic Normal Safety Procedures (NSP); any safety rules being broken more than (2) times you are asked to leave the range for the safety of the other students and instructors, you will be offered safety training again and be invited back to the range after 24 hours with a final warning.
- If you fail to adhere to the final warning; you will be asked to leave the course and academy and your project will end with UCP Group Inc., its associates and its affiliates including: accommodation at the academy, future learning on this project and airport transfers.
- Any aggressive behaviour; including political, sexual, and religious connotations will be met with the exclusion of that participant from the academy. Any accommodation cost outside the academy will be met by that same participant.
- Living quarters cleanliness; all participants will keep their living quarters always clean including the bedroom, kitchen area and academy.
- Outside the academy; you must always be considerate to the general public as well as polite; respecting local culture and religion and policing rules.
- Awards and passing the course; all courses will have a written theory exam for general safety and standard shooting and weapons descriptions and identification as well as a practical session on accuracy and range discipline.
- Evaluation and Assessment; If the range officer feels you are not competent in the practical sessions or the IQA deems your answers on the written exam is not good enough then you will not be awarded the certificate.
- Final Mark; This course requires an 88% pass rate.
I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS FROM, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.
Print Name:   Full name of the participant*
Signature:   Participant’s signature*
Date:   Date of signing*

Witness Name:   First Name   Last Name
Signature:   Signature
Date:   Date

PHOTO(s), VIDEO(s) & MEDIA FILE(s) RELEASE FORM
I, Full legal name of the student* address of Address* " the Releasor" grant permission and consent to, including but not limited to " the Releasee" UCP Group Inc., associates, and affiliates " ENTITIES & INDIVIDUALS", and any acting agents for the mentioned, staff, instructors and private contractors for the use of my personal or group photograph(s) Video(s), and media files for presentation, including but not limited to: publicity, copyright purposes, illustration, advertising, web content, media advertising and or in any way the company needs to use my photo(s) & Video(s) included but not limited to: marketing, recruiting, advertising, education, training and media.
I   Full legal name of the student*   agree not to use any images without the consent of the releasee.

I   Full legal name of the student*   agree not to take any images of the instructors or students in the classroom or ranges or in any other training grounds.

I   Full legal name of the student*    agree not to use the training images from the course that includes other participants, instructors, staff and agents.
I Full legal name of the student* agree not to use any images, videos, and media for marketing or social media or without previous consent from the Releasee.

I Full legal name of the student* agree and understand that if I am not wearing a mask I may not receive images from the Releasee.
Payment
✓* I understand that there shall be no payment for this release. InitialsType here*

Royalties
✓* I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.   InitialsType here*

Revocation
✓* I understand that with my authorization below the photograph(s), video(s) and media file(s)may never be revoked. InitialsType here*
The Releasee will be forced to take legal action, should any images be used or sent to anyone that has not signed an NDA with UCP. The Releasee has the right to take legal action, including charging a £100,000 fine if any images were proven to be leaked from one’s device. These images are neither to be sold nor used to train others by them or a third party. The Releasee also has the right to check media equipment if necessary.

This release " agreement" will be governed by the laws of USA.
We, the Releasor and Releasee, have understand and agree to the aforementioned terms and conditions.

Releasor’s Signature (Participant/Student or Guardian if under 18 ages of age sign here)

Name of Participant (Print full name):   Full legal name of the student*
Signature:   Participant’s signature* Date:   Date of signing*

Who is signing this form?
Signed by Participant   Signed by Parent/Guardian of participant (if participant is under 18 years of age) *
Releasee’s Signature (Up Close and Personal Group signs here)

Signature: Signature
Date: Date

Name*

First NameLast Name
Phone Number
Please enter your email address *

Confirmation EmailPlease confirm your email address
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UCP STUDENT HEALTH RECORDS

UCP CORONA VIRUS WAIVER

UCP CONSENT FORM

UCP LIABILITY & EMERGENCY CONTACTS

UCP RELEASE FORM

RANGE & HOSTILE ENVIRONMENT TERMS

PHOTO(s), VIDEO(s) & MEDIA FILE(s) RELEASE FORM