• All-State Camp Agreement

    Student Participant and Parental Permission Agreement

  • Assumption of Risk, Release, & Waiver of Liabitility and Emergency Medical Information

    Please read the participation agreement, parental permission agreement, assumption of risk, and release of liability carefully. It is a legal contract and affects any rights you and your student may have if your child is injured or otherwise suffers damages while participating in the Iowa Lakes All-State Camp.

  • Date of Birth *
     - -
  • Do you have any food allergies or dietary restrictions?*
  • Do you have any medical restrictions or disability-related accommodation needs?*
  • Format: (000) 000-0000.

  • Transportation

    As parent/guardian, I give my permission for the people named below to drop off and pick up my student. I understand my student will not be released to anyone else unless a change is made in writing by the parent/guardian.
  • My student is permitted to drive themselves to and from this camp:*

  • Medical Emergency Contact Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Health/Insurance Information

  • Iowa Lakes Community College does not provide health insurance for students at the Iowa Lakes All-State Camp. Your signature below verifies that you do not have health insurance and are aware that Iowa Lakes Community College does not carry any health insurance for you.

  • Should the student-supervisor be aware of any student's health condition, allergies, or medication?*
  • Is there any additional information we should be aware of about the student?*
  • Format: (000) 000-0000.
  • Is the student covered by health insurance?*

  • Room & Board

    Students who would like to stay overnight can stay in our Laker One Dorm on campus. Students staying in the dorms will receive supper Saturday evening and a continental breakfast on Sunday morning. The cost for the lodging and two meals is $30/student. 
  • Is the student staying in the dorms?*
  • Student Sex

  • If paying by check/cash, please make checks payable to Iowa Lakes Community College and mail to: 

    Iowa Lakes Communtiy College
    Brett Fuelberth
    300 South 18th St. 
    Estherville, IA 51334

  • Room and Board Payment

    prevnext( X )
      Overnight Room & Board for August 15
      $30.00$30.00
        
      Total
      $0.00$0.00

      Credit Card

    • Signatures

      By signing below, you are agreeing to all of the information you have listed/read on this form.

    • Behavior expectations of the participant: 

      It is important to follow the instruction of the Iowa Lakes All-State Camp staff personnel at all times. You must abide by the College's rules and conduct expectations. I understand that as a student, I have the responsibilty to help make the learning opportunity a safe experience for everyone through my experience for everyone through my behavior and conduct. I also understand the danger of not following rules and instructions and agree to following them. 

      Image/Voice Permission: 

      During activities, a photograph or video/audio recording(s) may be taken. Unless you request otherwise, your signature below will be considered permission for Iowa Lales to photograph, fillm, audio/video tape, and/or record your image or voice for use in any promotional materials. If you object to you image or voice being used, please notify bfuelberth@iowalakes.edu prior to participating. 

      Assumption of rishke and release of liability: 

      I, as the parent or legal guardian of the student attending this camp, grant permission for my student to participate in the Iowa Lakes All-State Cmapl. This Participation Agreement, Parental Permission Agreement, Assumption of Rish, Release of Liability and Emergency Medical Information must be read carefully and signed by the participant and the parent or legal guardian of each student under 18 years of age who will particapte. These activities may involve certain risks and possible injury, and that Iowa Lakes Community College will provide each participant with reasonable care, but cannot guarnetee they will remain free of injury. I nonetheless wish to participate and ASSUME the risk of particpating. I agree to RELEASE from LIABILITY, INDEMNIFY and HOLD HARMLESS Iowa Lakes Community College and high school directors, students, employees, and agents from any claim and cause of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my participation in the Iowa Lakes All-State Camp. This release, however, is not intended to release the RELEASEES mentioned above from liability arising out of their sole negligence.

      Medical Emergency Permssion

      I understand that I must be healthy and reasonably fit in order to participate in the Iowa Lakes All-State Camp safely. I will inform the directors of any medication, ailment, condition, or injury that may affect my ability to participate safely. The health history stated above is correct and complete to my knowledge. If an injury or other medical condition occurs or arises, I hereby give permission to the directors in charge to provide routine first aid and seek emergency treatment including X-rays or routine tests. I agree to the release of any record necessary for treatment, referral, billing or insurance purposes. I understand that I am financially responsible for charges and hereby guarantee full payment to the attending physicians or health care unit. In the event of an emergency where the emergency contact listed above cannot be reached, I give permission to the physician/hospital to secure and administer treatment for me, including hospitalization.

    • Date*
       - -
    • Date*
       - -
    • Should be Empty: