Medical Waiver/Emergency ContactI understand the risks involved in the sport of water polo, and that participation in the Gauchos Girls Water Polo camp could result in the injury, sickness or death of my child. I give my child permission to participate in all activities at camp. It is understood that this camp is not run by the University of California, Santa Barbara and that Gauchos Girls Water Polo Camp does NOT provide medical insurance covering injuries of any kind for the duration of the camp. The undersigned hereby releases Gauchos Girls Water Polo Camp, the University of California, Santa Barbara, its successors, officers, agents and employees from all claims, demands, and causes of actions resulting from participation in the water polo camp. I further hereby, on behalf of myself, my child and anyone claiming through myself or my child, do FOREVER RELEASE the University of California, Santa Barbara, its trustees, officers, employees, volun-teers, students, agents and assigns from any cause of action, claims, or demands of any nature whatsoever, including but not limited to a claim of negligence which I, my child, or anyone claiming through myself or my child, may now or in the future have against University of California, Santa Barbara on account of personal injury, bodily injury, property damage, death or accident of any kind, arising out of or in any way related to my child’s participation in the Camp howsoever the injury is caused.

I certify that my child is medically able to participate in the Camp and is free from any commu-nicable, infectious or contagious diseases.

In case of emergency, parent/guardian can be reached at:Home Phone __________________________________________________________________Cell Phone __________________________________________________________________Known Medical Conditions: ______________________________________________________

I hereby acknowledge that the aforementioned minor child is covered by medical insurance as follows:Insured Company_______________________________________________________________Policy Number _______________________________________________________________Company Phone # ____________________________________________________________

I hereby authorize the directors of Gauchos Girls Water Polo Camp to act with their best judg-ment in case of any emergency requiring medical attention.

Signature of Parent/Guardian______________________________ Date _______________

Print Parent/Guardian Name ______________________________________________________

Please include a printed copy of your insurance card with your registration.

Gauchos Girls Water Polo Camp • UC Santa Barbara ICA Building • Santa Barbara, CA 93106