MEDICAL LIABILITY, CONSENT AND RELEASE FORM
I, the undersigned, certify that I am the parent/legal guardian of __________________________________________________,
(Camper Name)
A minor, and that the camper is in good physical condition and able to participate in all activities sponsored by Rockhaven
Camp, a ministry of First Presbyterian Church. I consent to the participation of the Camper in any activity sponsored by the
camp in which the Camper elects to participate.
In case of physical injury, illness or medical emergency of Camper, I ask that you, the Camp representatives, make reasonable
attempts to contact me; however, if I cannot be reached, I authorize you to contact our family physician if he/she can be
reached, and to take whatever measures are necessary to ensure the safety and wellbeing of the Camper. This authorization
and consent authorizes physicians, dentists, and staff duly licensed as Doctors of Medicine or Doctors of Dentistry or other such
licenses, technicians or nurses to render the diagnosis, treatment or care they deem advisable for the Camper in the exercise of
their best professional judgment. I understand that every reasonable attempt to contact me will be made before providing
diagnosis, treatment or care, time and conditions permitting, but that diagnosis, treatment or care may be provided in an
emergency without my consent.
The undersigned parents, parent or guardian take full responsibility for any injuries incurred by the Camper, either in
transportation to or from or at permitted activities, and agree to release the Camp, Church, Officers, Director or Employees and
Volunteers (“RELEASEES”) from and against any loss, liability or claim for physical or bodily injury or death to the Camper arising
out of negligence of the Releasees in connection with or related to permitted activities. This release does not apply to
intentional infliction of injury or sexual misconduct of any sort by the Releasees.
The undersigned parents, parent or guardian represent to the Camp and Church that the Camper is currently covered by health
insurance listed in the Medical Form which applies (except for deductibles) to injuries arising out of Permitted Activities.
SIGNATURES OF PARENTS, PARENT OR GUARDIAN
I/We have read and agree to all of the above terms, including without limitation consent for my/our
child, the above Camper, to participate in Rockhaven camp activities, medical treatment consent, and
release of liability.
______________________________ __________________________________ ___________
Parent/Guardian Signature
Parent/Guardian Print Name
Date
______________________________ __________________________________ ___________
Parent/Guardian Signature
Parent/Guardian Print Name
Date
PERMISSION TO USE PHOTOS, DISTRIBUTE ADDRESS OR TRANPORT CAMPER
I give permission for the use of photographs or videos including my child’s image in camp publicity. Yes No
I give permission for the distribution of my child’s mail/email addresses to camp mates. Yes No
I give permission for First Presbyterian Church to transport my child. Yes No
________________________________________________________________________ _____________
Parent /Guardian Signature
Date
ROCKHAVEN CAMP
A Ministry of First Presbyterian Church, Bozeman, MT
PO Box 1150 Bozeman, MT 59771
Phone: 406.586.9194 Ext. 267 Fax: 406.587.3726 Email: scott@rockhavencamp.org Web Site: