DUKE CATHOLIC CENTER BEACH WEEKEND REGISTRATION FORM
Beach Weekend: Sept 8-10, 2017
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DUKE MEDICAL INFORMATION FORM
PARTICIPANT INFORMATION
Dietary Needs? *
Allergies, vegetarian, gluten-free, etc.
Your answer
Participant First Name *
Your answer
Participant Last Name *
Your answer
Date of Birth *
mm/dd/yyyy
Your answer
Gender *
Your answer
Cell Phone *
Your answer
Email *
Your answer
Home Phone *
Your answer
Permanent Address *
Street and number
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Country
Your answer
MEDICAL EMERGENCY CONTACT INFORMATION
PERSON TO CONTACT FIRST
First Name *
Your answer
Last Name *
Your answer
Relation to Participant *
Your answer
Daytime Phone *
Your answer
Evening Phone *
Your answer
Are you allergic to any medications? *
If no, please type "N/A"
Your answer
List current perscriptions/medications *
If none, please type "N/A"
Your answer
Backup Contact (Relative or Friend)- First and Last Name *
Your answer
Relationship to Participant *
Your answer
Daytime Phone *
Your answer
Evening Phone *
Your answer
INSURANCE POLICY INFORMATION
Are you covered by health insurance? *
Your answer
Policy Holder's Name *
Your answer
Policy Holder's Date of Birth *
mm/dd/yyyy
Your answer
Address *
Number, Street, City, State, Zip
Your answer
Relation to Participant *
Your answer
Employer Address *
Your answer
Occupation *
Your answer
Insurance Company Name *
Your answer
Insurance Company Address *
Your answer
Policy Number *
Your answer
Plan Number *
Your answer
*Must be signed by parent or guardian if participant is under age 18
Please check the boxes to indicate that you have read and electronically sign.
Medical Assistance Agreement *
I hereby certify that my child will voluntarily participate in Duke Catholic Center’s Beach Weekend from September 8-10, 2017 in Salter Path, NC and I hereby grant permission to those appropriate personnel of the Beach Weekend program, including student site leaders, to seek medical assistance for my child should the same be required, recognizing that neither DUKE CATHOLIC CENTER nor any other entity or individual involved with the Beach Weekend program assumes responsibility for, nor do they have any liability for, the medical assistance and care which may be so selected and provided.
Required
Initials *
Your answer
Date *
Your answer
DUKE UNIVERSITY PARTICIPATION AGREEMENT
You have requested to participate in Duke Catholic Center’s Annual Beach Weekend from September 8-10, 2017 in Salter Path, NC. All activities, including those associated with travel, involve risks and it is important for you to have information about this activity and to provide the Duke Catholic Center with information about yourself before participating in this activity. The Participation Agreement must be read carefully and signed by all participants who take part in the activity offered by THE DUKE CATHOLIC CENTER.
PLEASE READ THIS AGREEMENT CAREFULLY
IT IS A LEGAL CONTRACT AND AFFECTS ANY RIGHTS YOU MAY HAVE IF YOU ARE INJURED OR OTHERWISE SUFFER DAMAGES WHILE PARTICIPATING IN THIS ACTIVITY.

Please check the boxes to indicate that you have read and electronically sign.

Participation Agreement *
In consideration of Duke University allowing me to participate in this activity, I agree and understand the following: 1. Risks of Activity: The risks of the proposed activities include but are not limited to personal property damage and bodily injury including strains, sprains, fractures, dismemberment, paralysis, or death. 2. Nature of Risk and Travel: I understand that I will be participating in activities including but not limited to: travel to Salter Path, NC and back to Durham, NC by chartered bus, structured and unstructured recreational and physical activities including games and team builders, and structured and unstructured service and worship activities. I also understand that the area of travel is coastal in nature and I may be participating in voluntary activities in both fresh and salt water. 3. Inherent Risks and Dangers of Travel: I understand and appreciate that risk and dangers are inherent when traveling long distances. I understand that not following procedures correctly could result in property damage and personal injury, including death. I agree to accept and assume all risks associated with the activities whether present or future, known or unknown, arising from or as a result of, my voluntary participation in the activities. Understanding all of the risks involved, I hereby elect to voluntarily participate. 4. Behavior Expectations of the Participant: I know that it is important to follow the directions of the activity leader at all times. I understand that as a participant I have the responsibility to help make the activities a safe experience for all participants through appropriate behavior and conduct. I also understand the danger associated with deviating from the planned activity and agree not to deviate from the plans as stipulated in the procedures. 5. Health Condition of the Participants: By signing this participation agreement you agree:  To furnish the DUKE CATHOLIC CENTER staff with your health information.  To inform the DUKE CATHOLIC CENTER staff of any medication, ailment, condition, or injury that may affect your performance in the activities.  That Participant will bear all financial responsibility for any medical treatment arising from participation in the activity.  I understand that the University reserves the right to make cancellations, changes or substitutions in cases of emergency or changed conditions or in the interests of the group.  I understand that as a participant in this Duke University program, I am a representative of Duke University. By signing this agreement, I pledge to conduct myself in a manner, which reflects favorably on all.  I understand that Duke University requires all participants to be covered by appropriate health and accident insurance and those participants and their families must be financially responsible for all medical expenses and for expenses related to evacuation and repatriation unless otherwise provided. Duke University also recommends that participants insure their property against loss or theft. 1. RELEASE, ASSUMPTION OF RISK, WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT In return for Duke University allowing me to participate in this activity and having read and understood this Participation Agreement, I hereby state that I voluntarily agree to the following: A. I hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE, the Duke Catholic Center, board members, employees or agents, Duke University, its trustees, officers, employees or agents, (hereinafter referred to as RELEASEES) for any liability, claim, and/or cause of action arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me that occurs as a result of my traveling to and from, and participation in this activity. B. I agree to INDEMNIFY AND HOLD HARMLESS the RELEASEES whether injury or damages is caused by my negligence, the negligence of the RELEASEES or the negligence of any third party from any loss, liability, damage or costs, including court costs and attorneys’ fees, that RELEASEES may incur due to my traveling to and from, and participation in this activity. C. It is my express intent that this RELEASE and HOLD HARMLESS AGREEMENT shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVER, DISHCARGE and COVENANT NOT TO SUE the above-named RELEASEES. D. I hereby further agree that this Participation Agreement, Release, Assumption of Risk, Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the state of North Carolina. E. If I deviate from any aspect of this activity, such deviation is purely voluntary, and I agree that RELEASEES shall not be liable for any injuries resulting or arising out of such deviation. F. I understand that by participating in this activity I will ASSUME THE RISK of injury and damage from risks and dangers that are inherent in any activity. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT that I have read the foregoing PARTICIPATION AGREEMENT, understand it, and sign it voluntarily.
Required
Initials *
Your answer
Date *
Your answer
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