Youth Protection Program Form

CAMPER/YOUTH PARTICIPANT

First Name

Preferred Name

Last Name

Date of Birth

Address

Country

Street

City

Region

Postal Code

PARENT/LEGAL GUARDIAN INFORMATION

Relationship to Participant

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Phone Number

Parent/Guardian 1 Email Address (Primary Communication Method)

Do you want to add another Parent/Guardian?

Yes

No

Second Relationship to Participant

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Phone Number

Parent/Guardian 2 Email Address

If neither parent/legal guardian is available in an emergency, please contact:

Full Name:

Phone Number:

Full Name:

Phone Number:

HEALTH INFORMATION

Health Insurance Carrier:

Policy Number:

Plan/Group Number:

Physician Authorization Required?

Yes

No

Family Physician:

Phone:

Special health conditions/concerns (major past illness, operation, serious injury) or other health history the program staff should know?

Yes

No

Please explain health history here:

I certify the above-named participant’s name had a pre-activity clearance examination (physical) within the last 14 months. I know of no impairments that would limit participation in all program activities. I further certify the participant is free from any contagious diseases

Yes

No

If NO, please explain:

Immunizations to date and in accordance with Texas (or home state) Department of State Health Services?

Yes

No

If NO, attach official documentation of TDHS exemption for Reasons of Conscience or a Physician’s Statement of Medical Contraindications.

Please use this area to upload a scanned or imaged copy of the required exemption or contraindication

Tetanus?

Yes

No

Tetanus Shot Date

Dietary restrictions?

Yes

No

Please explain the participants dietary restrictions:

Medication/Other Allergies?

Yes

No

Please list medications/Allergies here:

Will prescriptive or non-prescriptive medication need to be taken at the youth program?

Yes

No

How many medications will the participant need?

Medication:

Reason(s) for medication:

Daily dosage / time(s) taken

Medication:

Reason(s) for medication:

Daily dosage / time(s) taken

Medication:

Reason(s) for medication:

Daily dosage / time(s) taken

Medication:

Reason(s) for medication:

Daily dosage / time(s) taken

Medication:

Reason(s) for medication:

Daily dosage / time(s) taken

Please use this uploader to upload a list of:
1) The medications
2) Their reasons
3) And the daily dosage /time(s) taken

I, the parent/legal guardian of the above-named participant, give permission to the staff of the UTPB youth program to administer the prescriptive medications listed above.

Yes

THE UNIVERSITY OF TEXAS PERMIAN BASIN YOUTH PROGRAMS DESIGNATED INDIVIDUALS WILL NOT DISPENSE NON-PRESCRIPTION OR PRESCRIPTION MEDICATION TO THE ABOVE-NAMED PARTICIPANT UNTIL THIS FORM IS COMPLETED AND SIGNED BY A PARENT/GUARDIAN. THE PARENT/GUARDIAN UNDERSTANDS IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO GIVE THE MEDICATION(S) DIRECTLY TO THE CAMP DIRECTOR OR DESIGNATED STAFF MEMBER IN INDIVIDUAL DOSAGE CONTAINERS, ORIGINAL PRESCRIPTION CONTAINERS, OR ENVELOPES CLEARLY LABELED WITH DOSAGE INSTRUCTIONS ON THE FIRST DAY OF THE YOUTH PROGRAM.

My child may possess and self-administer the following OVER THE COUNTER non-prescription medicine

and I affirm that my child understands and agrees that he/she will use the medication only according to the dosage instructions, and will not share or otherwise provide medication to any other person while at camp, and failure to do so is a violation of camp rules that will result in disciplinary action, up to and including removal from camp.

I, the undersigned, hereby release The University of Texas Permian Basin, its Board of Regents, officers, employees, and representatives from any and all liability in any way resulting or arising from the administering of the above medication.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I, the undersigned, authorize The University of Texas Permian Basin to release information concerning the medical status, medical condition, injuries, prognosis, diagnosis, and related personally identifiable health information of the participant to program staff. This information includes all relevant to participation in the youth program at or with UTPB

CONSENT TO TREAT

I, the undersigned, as the parent/ legal guardian of the aforementioned child (a minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor; and to provide or arrange necessary related transportation for minor to a healthcare facility for emergency services as needed. The attending provider, appropriate staff, and The University of Texas Permian Basin and its officers, regents, and employees shall not be responsible in any way for any consequences from said diagnostic, medical, and /or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.

INDEMNIFICATION AGREEMENT

I, the undersigned, as the parent/legal guardian of the aforementioned child who is a minor, under 18 years of age and I, the abovenamed parent/legal guardian am fully competent to sign this agreement. I give permission for Participant to participate in the above-referenced activity or trip. I acknowledge that the nature of the activity/trip may expose Participant to hazards or risks that may result in Participant’s illness, personal injury or death that may result from such participation and I hereby release the University of Texas Permian Basin, its governing board, officers, employees and representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury to Participant’s person, including his/her death, that may result from or occur during Participant’s participation in the activity/trip, whether caused by negligence of The University of Texas Permian Basin, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the University of Texas Permian Basin and its governing board, officers, employees, and representatives from liability for the injury or death or any person(s) and the damage to property that may result from Participant’s negligence or intentional act or omission while participating in the described activity/trip.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR THE PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO THE PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY/TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S NEGLIGENCE OR INTENTIONAL ACT OR OMISSION.

MEDIA RELEASE

I, the undersigned, as the parent/legal guardian of the aforementioned child who is a minor, under 18 years of age hereby grant full permission to The University of Texas Permian Basin to prepare, record, use, reproduce, publish, distribute and exhibit my child’s name, picture, portrait, likeness or voice, or any or all of them in or in connection with any medium, including, but not limited to, the production of web sites, still photography, motion picture film, television tape, film or soundtrack recording, scientific publication, or any other purpose The University of Texas Permian Basin deems appropriate.

I hereby waive all rights of privacy or compensation, which I may have in connection with the use of my child’s name, picture, portrait, likeness or voice, or any or all of them in or in connection with any medium, including, but not limited to, the production of web sites, still photography, motion picture film, television tape, film or soundtrack recording, scientific publication, and any use to which the same or any material therein may be put, applied or adapted by The University of Texas Permian Basin.

This consent and waiver will not be made on the basis of a future claim of any kind against The University of Texas Permian Basin and any of its agencies.

Parent/Legal Guardian Affirmation

Today's Date: