UC Berkeley Summer Camp Detailed Application Form

Free Native Youth Acting Camp

July 25-29, 2022
Application Form

Led by professional Native artists and designed for Native youth. This is a free performing arts and youth leadership sleep away camp, held on the campus of the University of California, Berkeley from July 25th - July 29th.
Applications are processed weekly. Expect to hear back from us within 7-14 business days regarding your application to the program. The deadline to apply is June 15th, 2022.
Camper Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Phone Number*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
What pronouns would you like us to use for you (check any that apply) (optional)

they/them/theirsshe/her/hershe/him/hisno pronouns - use my nameother/tell us
Please add any pronoun/gender information you'd like us to know.
Tribal affiliation*
Abilities?

Neuro-typicalNeuro-divergentAutismID (Intellectual Disability)DyslexiaI prefer not to sayOther
Is there anything you'd like to share with us about your abilities or disabilities, seen or unseen?
What accommodations can meet your access needs?
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
Home Number
Alt. Number
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
E-mail*
Enter the full names and a contact number for other individuals who are allowed to pick up your child.
Please share a sentence or two about your camper that would help our staff support them. Any and all information is helpful! Nothing is too small! We want the best for your camper!
How will your child arrive at camp and be returned home? Check in: Monday, July 25th at 12 noon. Check-out: Friday, July 29th between 1 pm - 2 pm*
Health Provider Information
Policy # (If none, please enter "none.")*
Insured's Name (If none, please enter "none")*
Medical Insurance Co. (If none, enter "none")*
Family Physician/Healthcare Facility *
Physician Phone *
Please upload front and back of Health Insurance Card

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Dietary Information
Does your child have any FOOD restrictions or allergies? If yes, please specify.*
Is your child a vegetarian?

YesNo
Does your child have a gluten allergy or intolerance?

YesNo
Will your child bring an Epi Pen to camp?

YesNo
Camper Medical History

AlterTheater keeps all personal information private and confidential. This information is important for our staff in the field to be prepared to support your camper.
Will your child bring an inhaler to camp?

YesNo
Allergies (Please list food allergies in the "Dietary Needs" section above)*

Bee stingsMedicationsIodineSeasonal AllergiesOther Allergies (non food)None
Explanation of allergies
Is your camper taking any medication?*

YesNo
If yes, please list all medications your child is taking (over-the-counter and/or prescription)
COVID-19 Health Screening

All campers and instructors are required to be fully vaccinated against COVID-19. Fully vaccinated means a person has received their primary series of COVID vaccines plus a booster shot after their primary vaccination series.
Has your child received their primary series of COVID vaccines plus a booster shot?*

YesNo
Please upload proof of your child's COVID-19 vaccinations (required: if you have trouble uploading your child's proof of vaccination, you can email it to: tanis@altertheater.org)

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Does your child have a medical exemption?*

YesNo
Please provide details about your child's medical exemption. Please note we might not be able to accommodate medical exemptions.*
Please upload your child's Doctor's note outlining their medical exemption to the COVID-19 vaccine.*

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Travel Scholarship
Would you like us to send you a travel scholarship application form?*

YesNo
Waivers

COVID-19 PARTICIPANT AGREEMENT (INCLUDING ASSUMPTION OF RISKS, RELEASE AND INDEMNIFICATION). REQUIRED FOR ALL CAMPERS. Minor Participant Waiver, Release, Indemnification of All Claims & Covenant Not to Sue. PLEASE READ THIS ENTIRE AGREEMENT CAREFULLY. IT AFFECTS THE LEGAL RIGHTS OF CAMPERS AND THEIR FAMILIES IN THE EVENT OF AN INJURY OR LOSS DUE TO COVID-19
SARS-Cov 2 / Coronavirus / COVID-19 Warning & Disclaimer:

AlterTheater has developed policies for Performing Arts & Youth Leadership Camp operations based on state, county and CDC guidelines. However, COVID-19 is an extremely contagious disease that spreads easily through person-to-person contact. COVID-19 can lead to severe illness, personal injury, permanent disability, and death. COVID-19 can be fatal to older people and people of any age with underlying health issues. In rare instances, children might contract “multi-system inflammatory syndrome in children (MIS-C)” due to potential COVID-19 exposure; while rare, this can cause serious illness or death in children. In addition, there is much we still don’t know about the novel coronavirus. Participating in camp programs or accessing University of California, Berkeley facilities could increase the risk of contracting COVID-19. While we are taking precautions and following national and state guidelines to limit the spread the coronavirus, AlterTheater cannot warrant that COVID-19 infection will not occur through participation in camp programs or accessing University of California, Berkeley facilities.
I agree to observe the following procedures:
I will alert AlterTheater if my child or anyone in our immediate or extended household has potential symptoms of COVID-19, such as fever, shortness of breath or persistent dry cough, in the 72 hours prior to the start of camp or at anytime during camp. Please initial below:*

Clear
I will alert AlterTheater if anyone in our household or to whom my child has been exposed is diagnosed with COVID-19 while my child is at Performing Arts & Youth Leadership Camp. Please initial below:*

Clear
I understand that camp may need to close on short notice due to government order, child or staff illness, or other emergency. Please initial below:*

Clear
If my child must be picked up, I will return to the camp as soon as possible or will send an authorized adult to pick up my child. Please initial below:*

Clear
I will do my best to take my child’s temperature the morning prior to camp drop off and not bring my child to camp if they have a temperature above 100.4 degrees or are showing signs/symptoms of illness. Please initial below:*

Clear
Waivers and Agreements

Please read the following waivers and agreements carefully. They include release of liability and waiver of legal rights, and deprive you of the ability to sue certain parties. By agreeing electronically, you acknowledge that you have both read and understood all text presented to you as part of the registration process.
In consideration of being allowed to participate in any way in AlterTheater related events and activities, the undersigned acknowledges, and agrees that:
The risk to have contact with individuals, who have been exposed to and/or have been diagnosed with one or more communicable diseases, including but not limited to COVID-19 or other medical conditions, diseases, or maladies does exist, and it is impossible to eliminate the risk that my child and their family members and other contacts could be exposed to and/or become infected through contact with or close proximity with an individual with a communicable disease. I recognize that, while AlterTheater is taking steps to eliminate exposures, it is not possible to maintain a 6 foot distance in a summer day camp or overnight program setting. I understand that AlterTheater is following recommendations from the CDC and other relevant organizations in social distancing, including in how they interact with my child, but will not always be able to maintain a 6 foot distance between children, educators, staff, or chaperones. I understand that if my child is exposed to COVID-19 that they may also bring exposure to anyone in the household including household members who are at higher risk for serious injury or death. I, a parent of a child, for myself and on behalf of such child, agree to release, indemnify, protect, and hold harmless, and promise not to sue, AlterTheater and/or any of its officers, directors, employees, agents, contractors, and insurers (the “Released Parties”), to the maximum extent permitted by law, with respect to any and all claims, demands, damages, attorneys’ fees, litigation costs, losses, or liabilities, including, but not limited to, claims for property loss, personal injury and/or wrongful death, which my child may suffer, arising out of or in any way related to my, or my child’s, participation in the Program. The claims hereby released and indemnified against include those caused by or arising from the negligence of a Released Party, or any of them. Please type your name to agree to the above COVID-19 waiver *
Participant Agreement

(INCLUDING ASSUMPTION OF RISKS, RELEASE AND INDEMNIFICATION). REQUIRED FOR ALL CAMPERS. PLEASE READ THIS ENTIRE AGREEMENT CAREFULLY. IT AFFECTS THE LEGAL RIGHTS OF PARTICIPANTS AND THEIR FAMILIES IN THE EVENT OF AN INJURY OR OTHER LOSS.
All Participants age 18 and older, including all teachers and chaperones, (referred to as “Adult Participants”), must sign this Participant Agreement. At least one parent or legal guardian (both referred to as “Parent”) must sign on behalf of themselves individually as well as on behalf of their minor child or ward (referred to as “Minor Participant”). The term “I” as used in this Participant Agreement refers to the Adult Participant and/or Parent. The term “Program” refers to the AlterTheater program in which a Participant has enrolled. In consideration of the Program, services, benefits and amenities provided by AlterTheater, a California Non-Profit Public Benefit Corporation, I hereby understand, acknowledge and agree as follows, on behalf of myself and my Minor Participant (if applicable):
Activities and Risks

Activities vary from program to program, and may include hiking, swimming, volleyball, basketball, or other recreational activities available on campus. I understand that the Program exposes Participants to a variety of risks and hazards, foreseen and unforeseen, some of which are inherent and cannot be eliminated without fundamentally altering the unique character of the Program. These inherent risks include, but are not limited to, environmental risks and hazards, including deep water; plants; insect stings and bites; exposure to allergens including food allergens; accidents; problems arising from a Participant’s loss of balance or inability to follow directions; and unpredictable forces of nature, including weather that may change to extreme conditions without notice. Possible injuries and illnesses include allergic reactions, including anaphylaxis; high altitude illnesses; sunburn, heatstroke, dehydration, and other heat related conditions; infectious disease; musculoskeletal injuries; and other possible serious conditions or injuries, including death.
Assumption of the Risks

I understand that the description of the risks involved in AlterTheater activities set forth above is not complete, and that other risks may result in property loss, personal injury, or death. On behalf of myself and my Minor Participant (if applicable), I agree to assume, to the maximum extent permitted by law, all risks of participation in the Program, whether known or unknown, and whether or not such risks are described above. I understand that participation in the Program is entirely voluntary, and I consent to participation with full knowledge of the possible risks of such participation. If the Participant is a minor child, I have discussed the Program activities and risks with them, and confirm that the child wishes to participate in the Program. I confirm that I, and my Minor Participant (if applicable) is/are physically and mentally capable of participating in all Program activities.
Release and Indemnification

I, an Adult Participant or Parent of a Minor Participant, for myself and on behalf of such Minor Participant, agree to release, indemnify, protect, and hold harmless, and promise not to sue, AlterTheater and/or any of its officers, directors, employees, agents, contractors, and insurers (the “Released Parties”), to the maximum extent permitted by law, with respect to any and all claims, demands, damages, attorneys’ fees, litigation costs, losses, or liabilities, including, but not limited to, claims for property loss, personal injury and/or wrongful death, which I or my Minor Participant may suffer, arising out of or in any way related to my, or my Minor Participant’s, participation in the Program. The claims hereby released and indemnified against include those caused by or arising from the negligence of a Released Party, or any of them, but not those caused by their gross negligence or willful misconduct.
Medical Authorization

I represent that the medical information I have provided above is current, accurate and complete. I authorize AlterTheater staff to administer first aid, including, where permitted by applicable law, the administration of epinephrine by auto-injector, as well as the administration of “over the counter” medications, including aspirin, Tylenol, ibuprofen, Benadryl, Neosporin, Imodium, laxatives and similar medications. If my Minor Participant has a known life-threatening allergy, or if I have been advised by a health-care provider that the Minor Participant should be prepared for a possible serious allergic reaction, my Minor Participant has been provided with auto-injectable epinephrine and has been instructed by a physician as to its use; in addition, I have instructed my Minor Participant to have the auto-injectable epinephrine on their person and available at all times during the Program. If my Minor Participant is enrolling in the Program as part of a school or other group, I have also informed the person in charge of the school or other group of this allergy and any applicable physician - prescribed protective measures. I authorize any adult chaperone or member of AlterTheater staff to obtain medical care for my Minor Participant (or for me, if I am unable to consent), and hereby consent to any X-ray, examination, anesthetic, diagnosis, treatment and/or hospital care that may be recommended by a licensed physician and/or dentist. In the event of minor illnesses or injuries, I understand that AlterTheater will attempt to contact me at the earliest practicable opportunity. In the event of a major illness or injury, I understand that AlterTheater will attempt to contact me before the commencement of any medical treatment, unless my Minor Participant’s condition is such that treatment must be commenced immediately before contact with me can be made. If I cannot be reached, this authorization remains in full force and effect. I agree to assume full financial responsibility for the costs of any early departure, and/or medical care or treatment that I or my Minor Participant may receive (including transportation to and from the Program). I understand that AlterTheater may find it necessary to terminate the Program or an activity within the Program, whether due to forces of nature, medical necessity, problems in the group or other reasons that AlterTheater, in its sole discretion, deems prudent, and agree that it may do so. I understand that AlterTheater reserves the right to refuse participation to any person who AlterTheater determines, in its sole discretion, may present a risk of harm to themselves or others, and agree that it may do so.
Other Provisions
I agree that AlterTheater and/or its designees may use for any purpose, without restriction or compensation, my likeness, and/or that of my Minor Participant, whether photographs, video, or any other media as well as any writing, artwork and/or testimonials created by me or my Minor Participant and submitted to AlterTheater. AlterTheater may also conduct educational surveys involving myself or my minor Participant and share these surveys with partner research organizations. I agree that once submitted, these materials shall become the property of AlterTheater and may be used for marketing or educational evaluation purposes. I understand that during part of the Program, my Minor Participant will be under the supervision of teachers, chaperones, and other adults who are not AlterTheater employees, and who have not been selected, and are not supervised, by AlterTheater. I understand and agree that AlterTheater is not responsible for the actions of any such individuals. AlterTheater uses independent contractors for some services, and such independent contractors, and not AlterTheater, are solely responsible for any losses or injuries caused by their acts or omissions. I understand that this Participant Agreement is intended to have as broad an effect as the law permits, and that if any part of this Participant Agreement is found to be invalid for any reason, the remainder of the Participant Agreement shall remain valid and fully enforceable. I agree that if there is a dispute between me or my Minor Participant, on the one hand, and a Released Party, on the other, such dispute will be governed by the substantive laws of the State of California. I have been advised to consult with an attorney of my choosing if I have any questions concerning the provisions and/or translation of this Participant Agreement. I certify that I have carefully read this Participant Agreement, I understand its terms, and am signing it voluntarily. I have had any questions concerning the Program answered to my satisfaction. I understand that in the event of any dispute or issue regarding any translation of this Participant Agreement, the English version of this Participant Agreement shall control. Please type your name to agree to the Participant Agreement *
Medical Release and Authorization As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to AlterTheater and its affiliates including teachers, chaperones, and staff to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by AlterTheater during the selected camp. In exchange for the acceptance of said child’s candidacy by AlterTheater, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless AlterTheater and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against AlterTheater including all teachers, chaperones, staff and afilliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Free Native Youth Acting Camp

Application Form

Applications are processed weekly. Expect to hear back from us within 7-14 business days regarding your application to the program. The deadline to apply is June 15th, 2022.

Camper Information

Parent/Guardian Information

Emergency Information

Health Provider Information

Dietary Information

Camper Medical History

COVID-19 Health Screening

Travel Scholarship

Waivers

SARS-Cov 2 / Coronavirus / COVID-19 Warning & Disclaimer:

I agree to observe the following procedures:

Waivers and Agreements

In consideration of being allowed to participate in any way in AlterTheater related events and activities, the undersigned acknowledges, and agrees that:

Participant Agreement

Activities and Risks

Assumption of the Risks

Release and Indemnification

Medical Authorization

Other Provisions