2019 PEAR-Camp Registration Forms Checklist - Pearland ISD
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2019 PEAR-Camp Registration Forms Checklist
There are a number of forms included in this packet that are required in order to complete the
registration process. Please complete, sign and return all of the forms to the Advanced
Academics office without delay. If there is a form that you believe is not applicable for your child
please indicate that on the form by writing “N/A” on the form before you return it to the office.
o STEM Discovery: San Francisco Interest Form
o Before & After-Camp Plans Form
o Medical Release Form
o Discipline Agreement
o Indoor Skydiving Waiver Form
o Check or money order made out to Pearland ISD: Advanced Academics in the amount
of $350.00 (for PEAR-Camp only)
• EF Tours will manage trip extension payments through EF website.
Please feel free to contact Heather Block, Coordinator of Advanced, International, and Innovative
Programs if you have any questions regarding these forms or about PEAR-Camp (281-485-3203 or
blockh@pearlandisd.org)
Mail to:
PEAR-Camp by Advanced Academics
Checks payable: PISD/Advanced Academics1928 N. Main Street
Pearland, TX 77581
(281) 485-3203
STEM Discovery: San Francisco
Information:
Well known as the home of some of the world’s most recognizable technology companies, it’s no surprise that San
Francisco has a thriving culture built on science, technology, engineering, and math. Lately, many tech companies
have shifted back from Silicon Valley to San Francisco as the emphasis on tech has shifted from hardware to
software. During your tour of this foggy, tech-friendly city, you’ll discuss environmental conservation in a redwood
forest, have a real-life “Shark Tank” experience as you listen to startups pitch investors at the Plug and Play Tech
Center, and explore the artsy side of tech with a visit to the Autodesk Gallery.
What is included:
• Airfare and transportation • Guided tours and activities
• Hotel accommodations • Full-time tour direction
• Overnight Security • Traveler resources
• Meals • 24-hour emergency service
• All gratuities
Date of trip:
DEPARTURE: 7/28/19
RETURN: 8/2/19
Group leader:
Heather Block
blockh@pearlandisd.org
Where to sign up:
https://www.efexploreamerica.com/tour-website/2157679AZ
Cost: $2,644
Who is able to participate?
STEM Discovery: San Francisco is for entering 7th and 8th grade students who are interested in the S.T.E.M. field. Interest
in this field means committing to (or plan to take/participate) at least two of the following courses/clubs:
o Intro to Algebra (7th grade) o Participation in TMSCA
o Algebra I (8th grade) o Participation in campus robotics club
o Integrated Physics and Chemistry o Pear Camp
o Robotics, Programming, & Design2019 PEAR-Camp BEFORE & AFTER CAMP PLANS FORM
Please Complete One Form for Each Child in Camp
Pearland ISD does not provide transportation to/from PEAR-Camp.
Child’s Name:
_________________________________________________________________________
I understand that my child will be met and signed out at Rogers Middle School by parent or
authorized person at 4:00 pm.
_________________________________________________________ ________________
Parent/Guardian Signature Date
___________________________________________________________________
Parent/Guardian Name (please print)
Please choose from the options below and check the boxes that work best for your family. Make
sure to check at least one option for morning and one for afternoon even if you think your plans
may change.
Before & After Camp Child Walking To & From Camp:
□ Child will walk to Rogers Middle School in the morning.
□ Child will walk home from Rogers Middle School in the afternoon.
Before & After Camp Parent Drop Off &/or Pick Up:
□ Morning Drop Off by Authorized Person.
□ Afternoon Pick Up by Authorized Person.
Authorized Person other than parent for drop-off/pick-up:
1. Name: ______________________________________________________________________
Relationship to student: _____________________ Phone number: _____________________
Texas Driver’s License: ________________________
2. Name: ______________________________________________________________________
Relationship to student: _____________________ Phone number: _____________________
Texas Driver’s License: ________________________
3. Name: ______________________________________________________________________
Relationship to student: _____________________ Phone number: _____________________
Texas Driver’s License: ________________________
Signature of Parent or Guardian: ____________________________________________Date:__________Emergency Contact Information
Student’s Name_____________________________________ Date of Birth____________________
Address______________________________________ Home Phone#___________________________
Parent/Legal Guardian______________________________________
Parent’s Employer_____________________________ Work phone #____________________
Emergency Phone Numbers
It is important to be able to contact parents at any time. Please list daytime/night phone numbers, cell phone numbers,
and pagers.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Medication: (if the student generally takes medication during school day, it is appropriate to take medication during camp)
If your student will need to take any type of medication (over-the-counter or prescription) during the
camp, please carefully read and complete the Authorization for Administration of Medication form.
Write on the back or attach extra pages if necessary.
Medical History
Date of last Tetanus shot________________ Allergies_________________
Pertinent Medical History:
Activity Restrictions:
Chronic Health Problems:
Medical Insurance Company ______________________________ Phone __________________
Name of Insured__________________________________ Policy Number_________________
In case of an emergency and a parent cannot be reached by phone, I authorize Margo Gigee, Heather Block, or Scott Jackson to obtain
medical treatment for my son/daughter and any hospital emergency physician and/or any member of the hospital medical staff requested
by a hospital emergency department physician to make such examinations, and render such medical and/or surgical treatment which is
in his or her judgment may be deemed necessary for my child’s health and welfare.
Signature of parent/legal guardian___________________________________________________________
We must have phone numbers at which we can reach parents any time during the camp.
Please attach a copy of the insurance card.PEAR-Camp DISCIPLINE AGREEMENT
NAME: _________________________________________________ ______________________
At PEAR-Camp, we take respect very seriously. We expect you to show respect in the following ways:
RESPECT YOURSELF:
A. MAKE APPROPRIATE CHOICES. Follow the expectations that your teachers and the Pear-Camp staff present. If you are not sure whether a
choice is appropriate, ask an adult. The better you do at following expectations, the more time you’ll have to enjoy the fun atmosphere at Pear-
Camp.
B. MAKE THE EFFORT TO SUCCEED. There will be lots of new experiences to try at Pear-Camp. Don’t limit your fun by only doing things that
you’ve done in the past. Try new things.
C. MAKE SAFE CHOICES. We have many cool activities to keep you busy during your day. By making safe choices, you’ll be able to enjoy these
activities.
D. BE TRUE TO YOURSELF! Be honest with people. If you are uncomfortable with something, let someone know. Tell the truth – people will
respect you a whole lot more if you do.
RESPECT YOUR PEERS:
A. TREAT OTHERS THE WAY YOU WANT TO BE TREATED. Working with your peers for two weeks can be a lot of fun if everyone treats
each other with respect. Give people compliments and put-ups. Be supportive. Encourage others to try as hard as they can.
B. MAKE APPROPRIATE CHOICES. In a small community, your actions and words affect many people. By following expectations, you will make
the two weeks much more fun for your classmates (and they will probably do the same for you!).
C. WATCH FOR THE SAFETY OF YOUR CLASSMATES. During many activities, your classmates will rely on you to stay safe. It is your
responsibility to help them stay safe.
D. RESPECT OTHER PEOPLE’S PROPERTY. Make sure you ask permission before using someone else’s stuff. If you borrow something, return
it in the same condition it was in when it was lent to you.
RESPECT YOUR INSTRUCTORS:
A. MAKE APPROPRIATE CHOICES. If you follow our instructor’s expectations, they will have time to show you a bunch of fun games and
activities. The more you demonstrate that you are able to make responsible decisions, the more responsibility your instructors will give you!
B. LET YOUR INSTRUCTORS KNOW WHERE YOU ARE! Your teachers and parents expect you to be supervised the entire time you are here.
We expect you to help us by staying with the group.
C. BE AN ACTIVE LISTENER. Our instructors have many amazing things to show you. When they ask for your attention, you need to show good
listening skills. A good listener focuses on the instructor and asks questions after raising his or her hand.
RESPECT YOUR PROPERTY:
A. CLEAN UP AFTER ONES SELF. Work areas should be kept clean and neat at all times. Work surfaces are to be cleaned at the end of each
laboratory or activity. Solid chemicals, metals, matches, filter papers, broken glass, and other materials designated by the instructor are to be
deposited in the proper waste containers, not in the sink. Follow your instructor’s directions for disposal of waste.
AS LONG AS YOU RESPECT OTHERS AND HELP KEEP PEAR-CAMP A SAFE PLACE, BOTH PHYSICALLY AND
EMOTIONALLY, FOR EVERYONE INVOLVED, YOU WILL HAVE AN AMAZING TWO WEEKS. IF YOU HAVE A
DIFFICULT TIME MAKING APPROPRIATE DECISIONS, THEN WE WILL DISCUSS OUR THREE STRIKES POLICY:STRIKE 1: The first strike will result in discussing inappropriate choices with a member of our staff. Together, we will figure out
why the decision was inappropriate and figure out ways of keeping it from happening in the future.
STRIKE 2: For a second strike, students will discuss their actions with our staff and the camp administrator. In addition we will
contact the student’s parent(s) or guardian(s).
STRIKE 3: The third strike will result in the student being sent home for the remainder of PEAR-Camp.
ANY ACTIONS THAT POSE A PHYSICAL OR EMOTIONAL THREAT TO OTHER MEMBERS OF OUR COMMUNITY
WILL RESULT IN IMMEDIATE DISMISSAL (SUCH AS: FIGHTING, NOT FOLLOWING SAFETY EXPECTATIONS,
SEXUAL HARASSMENT, AND VERBAL THREATS).
T-Shirt Size:
Youth Sizes: Y-SM Y-M Y-L
Adult Sizes: SM M L XL
I UNDERSTAND WHAT IS EXPECTED OF ME AND WILL DO MY BEST TO MAKE APPROPRIATE CHOICES.
STUDENT SIGNATURE: _________________________________________ DATE: ________________________
I UNDERSTAND THE PEAR-CAMP DISCIPLINE POLICY. IF MY CHILD SHOULD BE EXPELLED FROM CAMP I
AGREE TO IMMEDIATELY PICK THEM UP.
PARENT/GUARDIAN SIGNATURE: ______________________________ DATE: ________________________3/4/2019 Urban Air Sugarland Waiver
RELEASE AND INDEMNIFICATION AGREEMENT
PLEASE READ THIS DOCUMENT CAREFULLY. BY SIGNING, YOU ARE GIVING UP LEGAL RIGHTS
This Release and Indemnification Agreement (Agreement) is entered into by the Adult Participant, and if any minor is named
below, the Adult Participant on behalf of and as parent or legal guardian for the Child Participant(s) in favor of Sugar Land
Urban Air LLC (Urban Air). Collectively and severally, Adult Participant and Child Participant are referred to as the Participant.
In consideration of Urban Air permitting Participant access to the Premises and the ability to participate in the Activities,
including the Activities that may occur in, about, or near 9848 Hwy 90A, Sugar Land, TX 77478 or any other premises owned
or operated by Urban Air wherever located (Premises), Participant agrees as follows:
1. Nature of the Activities. Urban Air operates a trampoline and adventure park, which offers Participants (a) the opportunity to
participate actively or passively, in trampoline and adventure park related activities, including, but not limited to, jumping,
dodgeball, volleyball, tumbling, foam pit jumping, aerobics, skydiving, ninja warrior course, battle beam, laser tag, soft play,
ropes course, climbing wall, roller coaster/sky rider, go carts, laser tag, bowling, bumper cars, cyber sports, mini golf, arcades,
exercising, and other miscellaneous trampoline and adventure activities, instruction, training, fitness classes, competition,
events, and programs and (b) access to the locker room, Premises, and cafe (collectively, Activities).
2. Types of Risks. Participant acknowledges there are inherent risks in and injuries that may occur from participating in the
Activities, including, but not limited to, cuts; bruises; muscle strain; twisted or sprained ankles, knees, shoulders, or wrists;
burns; dirt or other materials in eye; concussions; broken bones; physical or emotional injuries; landing wrong; over-exertion;
failure of the attraction surface or attachments; being hit by a ball; collisions with other participants; erratic co-participant
behavior; collisions with standards and supports; using improper form or technique; slipping, falling, or tripping; equipment
failure; error of judgment by employees; paralysis, disability, or death; personal injury to third persons; or property damage.
Due to the nature of the Activities, there are more hazards and risks than the foregoing, and there are also unknown and
unforeseeable hazards.
3. Assumption of Risks. Notwithstanding the foregoing risks and safety measures implemented by Urban Air, Participant
acknowledges it is impossible to eliminate all risk of injury and understands the demands of the Activities relative to
Participant’s physical condition and skill level. PARTICIPANT AFFIRMS THAT PARTICIPATION IN THE ACTIVITIES IS
VOLUNTARY AND PARTICIPANT KNOWINGLY, WITH UNDERSTANDING OF THE RISKS AND POTENTIAL
INJURIES, ASSUMES ALL RISKS INHERENT WITH THE ACTIVITIES AND ACCESS TO THE PREMISES.
4. Alcohol. Participant agrees to exercise ordinary and reasonable care and to not consume alcohol to the extent Participant’s
judgment is impaired. Participant understands the potential risks associated with the consumption of alcohol and acknowledges
Participant does not have and is not aware of any medical condition that would result in any injury to Participant due to
Participant’s consumption of alcohol. Participant assumes the risks associated with alcohol consumption and takes full
responsibility for Participant’s own actions, safety, and welfare. UNDER NO CIRCUMSTANCES WILL PARTICIPANT BE
ALLOWED TO PARTICIPATE IN ANY ACTIVITIES IF PARTICIPANT HAS CONSUMED ALCOHOL.
5. Release and Indemnity. TO THE FULLEST EXTENT PERMITTED BY LAW, ADULT PARTICIPANT ON BEHALF OF
HIMSELF, CHILD PARTICIPANT, AND THEIR HEIRS, EXECUTORS, AND REPRESENTATIVES RELEASES, AGREES
NOT TO SUE, AND SHALL INDEMNIFY URBAN AIR, UATP MANAGEMENT, LLC, UATP IP, LLC, UA ATTRACTIONS,
LLC, THE LEGAL OWNER OF THE PREMISES, THE LANDLORD, MORTGAGEES AND MANAGEMENT COMPANY OF
THE PREMISES, AND ANY OF THEIR LENDERS, PARENTS, AFFILIATES, SUBSIDIARIES, OFFICERS, DIRECTORS,
SHAREHOLDERS, MEMBERS, MANAGERS, PARTNERS, AGENTS, EMPLOYEES, CONTRACTORS, REPRESENTATIVES,
HEIRS, ASSIGNS, VOLUNTEERS, INDEPENDENT CONTRACTORS, EQUIPMENT SUPPLIERS, AND INSURERS OF
ALL OF THEM (COLLECTIVELY, PROTECTED PARTIES) FROM AND AGAINST ALL LIABILITIES, LOSSES, DAMAGES,
CLAIMS, DEMANDS, ACTIONS, SUITS, CAUSES OF ACTION, COSTS, FEES, AND EXPENSES (INCLUDING
REASONABLE ATTORNEY'S FEES AND COURT OR OTHER COSTS) (COLLECTIVELY, CLAIMS) RELATING TO,
RESULTING FROM, OR ARISING OUT OF OR ALLEGED TO HAVE ARISEN OUT OF (IN WHOLE OR IN PART) ANY
PROPERTY DAMAGE OR BODILY INJURY (INCLUDING DEATH) TO PARTICIPANT RESULTING IN ANY WAY FROM
(A) PARTICIPANT’S USE OF THE PREMISES, (B) PARTICIPANT’S ACTIVE OR PASSIVE PARTICIPATION IN THE
ACTIVITIES, (C) LOSS OR THEFT OF PERSONAL PROPERTY, (D) FROM THE CONSUMPTION OF ALCOHOL AT THE
PREMISES BY PARTICIPANT OR ANY OTHER INVITEE OF URBAN AIR, OR (E) PARTICIPANT’S BREACH OF THIS
AGREEMENT. THIS RELEASE AND INDEMNITY SHALL APPLY EVEN IF ANY THE CLAIM IS CAUSED IN WHOLE OR
IN PART BY THE NEGLIGENCE, GROSS NEGLIGENCE, STRICT LIABILITY, OR WILLFUL MISCONDUCT OF THE
PROTECTED PARTIES OR PARTICIPANT. THE INDEMNITY SHALL ALSO INCLUDE ADULT PARTICIPANT’S
OBLIGATION TO INDEMNIFY THE PROTECED PARTIES FROM (Y) ANY SUM OR SETTLEMENT PAID TO OR ON
BEHALF OF THE CHILD PARTICIPANT RESULTING FROM A CLAIM IN ANY WAY INVOLVING THE FOREGOING
SUBSECTIONS AND (Z) ALL CLAIMS RESULTING FROM OR RELATING TO ANY INSUFFICIENCY OF
PARTICIPANT’S LEGAL CAPACITY OR AUTHORITY TO EXECUTE THIS AGREEMENT FOR OR ON BEHALF OF THE
CHILD PARTICIPANT.
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6. Dispute Resolution.
A. Arbitration. Any dispute or claim arising out of or relating to this Agreement, breach thereof, the Premises, Activities, property
damage (real or personal), personal injury (including death), or the scope, arbitrability, or validity of this arbitration agreement
(Dispute) shall be brought by the parties in their individual capacity and not as a plaintiff or class member in any purported
class or representative capacity, and settled by binding arbitration before a single arbitrator administered by the American
Arbitration Association (AAA) per its Commercial Industry Arbitration Rules in effect at the time the demand for arbitration is
filed. Judgment on the arbitration award may be entered in any federal or state court having jurisdiction thereof. The
arbitrator shall have no authority to award punitive or exemplary damages. If the Dispute cannot be heard by the AAA for any
reason, the Dispute shall be heard by an arbitrator mutually selected by the parties. If the parties cannot agree upon an
arbitrator, then either party may petition an appropriate court to appoint an arbitrator. Arbitration and the enforcement of any
award rendered in the arbitration proceedings shall be subject to and governed by 9 U.S.C. § 1 et seq.
B. Waiver of Jury Trial. TO THE EXTENT PERMITTED BY LAW, ADULT PARTICIPANT AND URBAN AIR KNOWINGLY,
willingly, AND VOLUNTARILY, WITH FULL AWARENESS OF THE LEGAL CONSEQUENCES, AFTER CONSULTING
WITH COUNSEL (OR AFTER HAVING WAIVED THE OPPORTUNITY TO CONSULT WITH COUNSEL) AGREE TO
WAIVE THEIR RIGHT TO a JURY TRIAL OF ANY DISPUTE AND TO RESOLVE ANY AND ALL DISPUTES THROUGH
ARBITRATION. The right to a trial by jury is a right parties would or might otherwise have had under the Constitutions of the
United States of America and the state in which the Premises is located.
7. License. Participant irrevocably grants the Protected Parties the right to use all or a portion of an image or video of Participant
and their name and likeness in all forms and media including composite or modified representations for all purposes, including
advertising, trade or any commercial purpose throughout the world and in perpetuity. PARTICIPANT WAIVES THE RIGHT
TO INSPECT OR APPROVE VERSIONS OF IMAGES OR VIDEOS USED FOR PUBLICATION OR THE WRITTEN COPY
THAT MAY BE USED IN CONNECTION WITH THE IMAGES/VIDEOS. PARTICIPANT RELEASES THE PROTECED
PARTIES FROM ANY CLAIMS THAT MAY ARISE REGARDING THE USE OF PARTICIPANT’S STATEMENTS, VIDEOS,
OR IMAGES INCLUDING ANY CLAIMS OF DEFAMATION, INVASION OF PRIVACY, OR INFRINGEMENT OF MORAL
RIGHTS, RIGHTS OF PUBLICITY, OR COPYRIGHT.
8. Authority. If Adult Participant signs this Agreement on behalf of his/her spouse, child, family member, friend, minor child, or
other person, Adult Participant warrants and represents to Urban Air that he/she has the legal authority and such person’s
actual and implied authority to execute this Agreement on their behalf, including, but not limited to, the arbitration clause,
release, indemnity agreement, and license.
9. Acknowledgments. Participant represents to the Protected Parties that this Agreement is a complete and final release and
indemnity agreement, that Participant is voluntarily entering into this Agreement, and no representations, promises, or
statements made by any of the Protected Parties has influenced Participant in signing this Agreement. Participant agrees that
there are no oral agreements, representations, promises, or warranties that are not expressly set forth herein, this Agreement
may only be modified in writing, and that Participant is not relying on any statements or representations of the Protected
Parties that are not expressly contained herein. Participant expressly agrees that this Agreement is intended to be as broad
and inclusive as is permitted by the laws of the state in which the Premises is located and that if any portion thereof is held
invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Venue for any action brought
hereunder or due to Participant’s
use of the Premises or participation in the Activities shall lie in the County in which the
Premises is located. The substantive laws of the state in which the Premises is located shall apply . By signing below,
Participant authorizes Urban Air to communicate with Participant via email with updates, news, advertisements, and offers.
10. Representations by Participant. Participant represents to the Protected Parties as follows:
A. Participant shall obey all rules while participating in the Activities and alert the staff of any rules violations or dangerous
behavior.
B. Participant possesses a sufficient level of skill and physical fitness for safe participation in the Activities.
C. Participant shall only attempt Activities that Participant can perform safely.
D. Participant is not aware of any health problems that would prevent him/her from participating in the Activities.
E. Participant has received either medical clearance from his/her physician prior to participation in the Activities or has determined
that such clearance is not necessary for his/her safe participation in the Activities.
F. Urban Air may, but shall not be obligated or required to, administer to Participant emergency aid, CPR, and use an AED
(defibrillator), secure emergency medical care or transportation (i.e., EMS), and Participant shall assume all costs of emergency
medical care and transportation.
G. Participant shall discontinue participation in the Activities if Participant feels any unusual discomfort (e.g., faintness, shortness
of breath, high anxiety, or chest pains).
BY EXECUTING THIS AGREEMENT, I REPRESENT I HAD A SUFFICIENT OPPORTUNITY TO READ THIS
AGREEMENT, I HAVE READ AND UNDERSTAND THIS AGREEMENT, AND I AGREE TO BE BOUND AS SET FORTH
HEREIN.
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Please select who will be jumping...
Adult Minor(s) Adult and Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors
This agreement is for a MINOR.
Minor's Name
First Name*
Middle Name
Last Name*
Minor's Date of Birth*
- Month - - Day - - Year -
Parent or Guardian's Email Address
Email*
Check to receive information, news, and discounts by e-mail.
Email me a copy of this document.
Parent or Guardian's Phone Number
Phone Number*
Emergency Contact
Emergency Contact's Name*
Emergency Contact's Phone Number*
Zip Code
I, the Parent/Guardian, on behalf of myself and that of the minor identified above, as applicable, have read the above
Assumption of Risk, Waiver of Liability, and Indemnification Agreement and fully understand and agree to its terms. I
understand that I am giving up substantial rights, including my right to sue, by executing this Agreement. I further
acknowledge that I am agreeing to indemnify Urban Air, as provided above, for all claims the referenced minor may have
against Urban Air. Lastly, I acknowledge that I am signing this Agreement freely and voluntarily, and intend my signature to
constitute a complete and unconditional release of Urban Air for all liability due to (1) ordinary negligence of Urban Air and
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those parties named herein and (2) to the inherent risks of the activity, to the greatest extent permitted by the laws of the
state in which the Urban Air is located. By signing below, the Parent or Court-Appointed Legal Guardian agrees that they are
also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Parent or Guardian's Date of Birth*
- Month - - Day - - Year -
I acknowledge and agree that by clicking to initial the boxes contained in this Agreement I am providing an electronic
signature as defined by the Electronic Signatures in Global and National Commerce Act ('E-Sign') and the Uniform Electronic
Transactions Act ('UETA').
Agree To This Document
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