Вы находитесь на странице: 1из 4

NSU Camp RiverHawks

GUEST GROUP RESERVATION AGREEMENT


Guest Group Name: _____________________________ Contact Person: _________________________
Address: ____________________________ City: ______________ State: _____ Zip Code: _________
Phone: ______________________ Email: _____________________________ Age of Group: ________
Purpose of Retreat: _________________________________ Est. Group Count: ____________________
Date of Event: _____________

Est. Time of Arrival: _____________


Est. Time of Departure: ___________

NSUs Camp RiverHawk desires to efficiently and effectively serve your group. In an effort to better
serve you, the following criteria have been established.

DEPOSIT, FEES AND CANCELLATION POLICY


Deposit: To reserve the requested dates a $100.00 non-refundable deposit must be submitted with this reservation
agreement. This amount will apply to your final balance.
Group Day Rates:
$350 Groups of up to 15
$500 Groups of up to 30
$400 Groups of up to 20
$550 Groups of up to 35
$450 Groups of up to 25
$600 Groups of up to 40
Includes access to canoes and canoeing equipment, recreation hall, kitchen space, meeting areas, and team building
activities.
Rental of meeting areas only- $50 a day Includes access to conference room, recreation hall, meeting areas, and kitchen
space.
Final Payment: Final payment of the outstanding balance is due upon arrival date listed above. If you wish
to pay in the form of a credit or debit card please note we can only accept this type of payment in the
Continuing Education office, please call 918.444.4610 to make a payment over the phone. If you would like to pay by
check, please make payable to NSU Continuing Education.
Cancellation: Cancellations must be made at least 5 days prior to the event. Cancellations made after this
time will forfeit any refundable amount. A full refund will be issued in the event that NSU cancels the
reservation due to inclement weather and other unforeseen circumstances.
Rules and Considerations: NSU Camp RiverHawks enforces a weight limit of 250 lbs. to participate in the high
elements of ropes course. Please wear closed-toe shoes and be mindful that wearing a harness hikes up shorts and pants.
Please refrain from wearing loose clothing and jewelry. We recommend long hair be tied back.

STATEMENT OF INTENT AND RESPONSIBILITY


We understand and will fulfill our responsibilities as detailed in the Reservation Agreement listed above. We further agree
to assume full responsibility for the supervision over and behavior of our group. In addition, we accept all liability for loss
or damage to equipment or property, and any and all medical expenses incurred by
our group during our stay at NSUs Camp RiverHawk.

____________________________

_____________________________

Group leader Signature

Financial responsibility Signature

______________________________
Date

______________________________
Date

NSU Continuing Education | NSU Outdoor Adventure Program


512 N Muskogee Ave. Tahlequah, OK 74464 | P: 918.444.4610 | F: 918.458.2361 | ce@nsuok.edu

Northeastern State University Continuing Education


Release of Liability and Medical Treatment Authorization Form
I, ____________________________________, understand that Northeastern State (NSU) Continuing Education
events, in which I plan to be a participant, involve certain risks and that regardless of the precautions taken by NSU, some bodily
injuries may occur. Specific risks/hazards involved in Continuing Education events include but are not limited to the following:
(1) auto accidents while traveling to and from events or traveling on the event premises; (2) dehydration; (3) physical injury
sustained while participating in events, both on and off campus (i.e. Tahlequah City Pool); and (4) medical problems such as
illness, allergies, etc.
1.
In consideration for receiving permission to participate in Continuing Education events, which are sponsored by NSU,
a component member of The Regional University System of Oklahoma (RUSO), I hereby release, waive, discharge, and covenant
not to sue, and agree to hold harmless for any and all purposes, NSU, RUSO and its Board of Regents, and their officers, servants,
agents, volunteers, or employees (herein referred to as RELEASEES) from ANY AND ALL LIABILITIES, CLAIMS,
DEMANDS, OR INJURY, INCLUDING DEATH, that may be sustained by me while participating in such activity, or while
on the premises that is owned, leased, or controlled by RELEASEES, including travel to and from NSU Continuing Education
events, including injuries sustained as a result of the negligence of RELEASEES. I understand this release does not apply to
injuries caused by intentional or grossly negligent conduct.

2.
I am fully aware that there are inherent risks involved with Continuing Education events and I choose to voluntarily
participate in said activity with full knowledge that said activity may be hazardous to me and my property. I acknowledge there
may be physically strenuous activities. I know of no medical reason why I should not participate. I voluntarily assume full
responsibility for any risks of loss, property damage, or personal injury, including death, which may be sustained by me as a
result of participating in said activity including injuries sustained as a result of the negligence of RELEASEES. I further agree
to indemnify and hold harmless the RELEASEES for any injury, death, loss, liability, damage or costs, including court costs and
attorneys fees, that may occur to any person(s) or property as a result of my participation in said activity including injuries
sustained as a result of the negligence of RELEASEES. I understand this agreement to indemnify and hold harmless does not
apply to injuries caused by intentional or grossly negligent conduct.
3.
I understand that RELEASEES may not maintain any insurance policy covering any circumstance arising from my
participation in this activity or any event related to that participation. As such, I am aware that I should review my personal
insurance coverage.
4.
It is my express intent that this Release shall bind the members of my family and spouse if I am alive, and my heirs,
assigns, and personal representatives if I am deceased, and shall be governed by the laws of the State of Oklahoma.

5.
I understand RELEASEES cannot be expected to control all of the risks articulated in this form but RELEASEES may
need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment
that may be required during my participation with the understanding that the cost of any such treatment will be my responsibility.
I agree to indemnify and hold harmless RELEASEES for any costs incurred to treat me, even if a RELEASEE has signed hospital
documentation promising to pay for the treatment due to my inability to sign the documentation.
6.
In signing this Release, I acknowledge and represent that I have read it, understand it, and sign it voluntarily as my own
free act and deed; no oral representations, statements, or inducements, apart from the foregoing agreement that has been reduced
to writing have been made. I execute this document for full, adequate, and complete consideration fully intending to be bound
by the same, now and in the future. I represent that I am eighteen (18) years of age or older and am otherwise competent to
execute this agreement. If the participant is younger than 18 then his/her parent or legal guardian must sign where
indicated on page 2 below. I consent to the information on this form being shared with the NSU Continuing Education Executive
Director, Director Staff, and Emeritus.

Page 1 of 2

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL CLAIMS
AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY PROPERTY THAT OCCURS
WHILE PARTICIPATING IN THE DESCRIBED EVENTS OR ACTIVITIES 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 MY NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
PRINT NAME ___________________________________________________ STUDENT ID# ______________________
DATE OF BIRTH ___________________________________________

GENDER (please check):

Male

Female

ADDRESS _________________________________________________________________________________________
CITY____________________

STATE _____________________

ZIP CODE________________________

PHONE NUMBER ____________________ DRIVERS LICENSE # _____________________ STATE OF ISSUE _____


PARTICIPANT SIGNATURE ________________________________________ DATE __________________________
Additional signature required if participant is younger than 18 years old during registered event dates

I am the parent or legal guardian of the participant indicated above, who is under the age
of 18 during the registered event dates. I agree on behalf of my child or ward to all the
terms contained in this Release.
PRINT PARENT OR LEGAL GUARDIAN NAME ___________________________________________________________
PARENT OR LEGAL SIGNATURE ________________________________________ DATE ____________________

In the event of an emergency, contact _________________________________

Phone_________________________

Health Insurance company

Policy #
(Indicate NONE if not covered by a health insurance plan.)

Doctors name

Phone

Please list any special services you may require due to an existing medical condition or physical disability, or any physical condition
limiting your activities: ________________________________________________________________________________________
___________________________________________________________________________________________________________
List any allergies to drugs, food, insects, plants, etc:_____________________________________________________________
List any medications you are taking: _________________________________________________________________________
List any dietary restrictions: _______________________________________________________________________________
Health History, please check that apply:
_______ Heart Condition/Disease

_______ Psychological Conditions

_______ Asthma

_______ Physical Disability

_______ Seizure Disorder

_______ Epilepsy

_______ Diabetes

_______ Other Disability

If any of the above are checked, please provide additional details:_____________________________________________________


_________________________________________________________________________________________________________
Do you wear glasses? Yes or No
Do you wear contacts? Yes or No
Do you have any swimming or water activity restrictions? Yes or No

If yes, please explain ___________________________

State law may require you to be informed of the following:


(1) you are entitled to request to be informed about the information about yourself collected by use of this form (with a few exceptions as provided by law); (2)
you are entitled to receive and review that information; and (3) you are entitled to have the information corrected at no charge to you.

Page 2 of 2

PHOTOGRAPHIC CONSENT AND RELEASE FORM


I hereby authorize Northeastern State University, and those acting pursuant to its authority to:
(a)

Record my likeness and voice on a video, audio, photographic, digital, electronic


or any other medium.

(b)

Use my name in connection with these recordings.

(c)

Use, reproduce, exhibit or distribute in any medium (e.g. print publications, video
tapes, CD-ROM, Internet/WWW) these recordings for any purpose that
Northeastern State University, and those acting pursuant to its authority, deem
appropriate, including promotional or advertising efforts.

I release Northeastern State University and those acting pursuant to its authority from liability for
any violation of any personal or proprietary right I may have in connection with such use. I
understand that all such recordings, in whatever medium, shall remain the property of the
Northeastern State University. I have read and fully understand the terms of this release.
Name:
Address:
Street

City

State

Phone:

Signature:

Date:

Parent/Guardian Signature (if under 18):


Date:

Zip