General Release And Authorization Form

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GENERAL RELEASE AND AUTHORIZATION
General Release
I have read the Parent Information Sheet detailing the nature and ministry of Impact Mission
Camps and I acknowledge and understand the information, release, and responsibility issues related with
Impact Mission Camps
Initial here _________
__________
Parent
Participant
Authorization for Treatment
I, the undersigned, for myself and/or on behalf of my child under 21 years of age, give permission for an
attending physician or hospital staff to administer medical care if deemed necessary by Impact Mission
Camps and the physician or hospital staff during the Impact Mission Camps project.
Initial here _________
__________
Parent
Participant
Release of Claims and Liability
I, the undersigned, for myself and/or on behalf of my child under 21 years of age, do hereby release from all
claims and forever hold harmless the directors, employees, and agents of Impact Mission Camps and the
Baptist General Association of Virginia from any and all claims and demands for personal injury, sickness
and death, as well as property damage and expenses of any nature incurred by myself or my child.
Initial here _________
__________
Parent
Participant
Release of Likeness
I, the undersigned, for myself and/or on behalf of my child under 21 years of age, give permission for
pictures and videos to be taken and used for promotion of the Impact Mission Camps project.
Initial here _________
__________
Parent
Participant
Assumption of Responsibilities
I, the undersigned, for myself and/or on behalf of my child under 21 years of age, do also assume
personal responsibility for all medical bills in excess of the applicable medical insurance plan provided
by Impact Mission Camps A copy of this policy is available from the Impact Mission Camps office.
Furthermore, I assume all costs for damages incurred by my child due to his or her negligence of rules and
restrictions placed on them by Impact Mission Camps And, should it be necessary for my child to return
home due to disciplinary action, medical reasons, or otherwise, I hereby assume responsibility for all
transportation costs.
Initial here _________
__________
Parent
Participant
Participant’s Signature
Date
Signature of Custodial Parent/Guardian
Date
Forms are not valid without proper initials and signatures in all areas
PLEASE BRING TWO COPIES WITH YOU TO THE PROJECT
(Do not mail this form to our office)

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