Form Ogc-Sf-2004-01 - Camp Genesis Registration, Release And Indemnification
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1
2Form No. OGC-SF-2004-01
Camp Genesis
Registration, Release and Indemnification Form
(Must use a separate form for each camper)
Camper’s First Name: _________________________________ Last: _________________________________________ MI: ___
Age (entering camp): ___ Grade (entering Fall ____): ___ Date of Birth: __________________
___ Male ___ Female
Address: ______________________________________________________________________________________________________
City: __________________________________________________ State: ________________ Zip: ___________________________
Mother/Guardian: ____________________________________ Home #: ______________ Cell/Pager #: __________________
Mother’s Employer: ___________________________________________________________ Work #: _______________________
Father/Guardian: _____________________________________ Home #: ______________ Cell/Pager #: __________________
Father’s Employer: ____________________________________________________________ Work #: _______________________
Child lives with: _______________________________________________________________________________________________
If parent cannot be reached, give name and relationship of person to be called in case of emergency:
Name: ________________________________________________ Relationship: __________________________________________
Home #: ______________________________ Work #: ______________________________ Cell/Pager#: ___________________
In order for any child to be fully registered and assigned a spot at Camp Genesis, all of the registration
materials including the registration form, payment, physical exam form and any/all waivers pertaining to
that week of camp, must be submitted at the time of registration. If a registration is mailed in or received in
the office incomplete, the parent/guardian will be notified and the child will be placed on the waiting list
and not guaranteed a spot, until the remaining materials are received. If the parent or guardian is claiming
to be a member of the Campus Recreation and Wellness Center they must also submit their Cougar Card
One number so that membership status can be verified. If for some reason the parent or guardian is found
to have sent the incomplete forms, they will be notified and the child will be placed on a waiting list until
the full payment amount is received. Signing below signifies that you have read and understood all
instructions.
Release, Indemnity, and Hold Harmless regarding Camp Genesis activities: As the parent/guardian I
am fully aware of the recreation activities that my child could participate in while attending Camp
Genesis including rock climbing, swimming in a pool containing water over a five foot depth, sports,
games and activities both in and out of doors that could include running, jumping and participating
at a level of high exertion. In this regard, I agree to release, indemnify and hold harmless the
University of Houston and its governing board, officers, employees, and representatives from liability
for the injury or death of my child; or damage to any property that may result from any activities
pertaining to Camp Genesis, including but not limited to those activities stated above. Should my
child require emergency medical treatment as a result of accident or illness arising during Camp
Genesis, I consent to such treatment. I acknowledge that the University of Houston does not provide
health and accident insurance for participants and I agree to be financially responsible for any
medical bills incurred as a result of emergency medical treatment. I will notify University
representatives in writing if my child has medical conditions about which emergency medical
personnel should be informed.
Signature of Parent/Guardian: ________________________________________________________ Date: __________________
If you are a member, provide your Cougar 1Card Number: ______________________________________________________
Office of the General Counsel
Standard Form Approved
Camp Genesis Registration, Release & Indemnification Form
by the University of Houston System
Office of the General Counsel
OGC-SF-2004-01 Revised 02.14.07
Page 1 of 2
Office of Contract Compliance
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