Sample Camp Release Form (Page 2 of 2) in pdf

4. M

EDICAL

ELEASE AND

ONSENT TO

MERGENCY

EDICAL

REATMENT

I authorize the camp and group leader(s) or camp medical personnel, in whose care my child has been entrusted, to consent to

any X-ray examination, diagnosis and/or treatment (i.e. anesthetic, medical, surgical, or dental), or hospital care to be rendered

to my child under the general or special supervision and on the advice of any physician or dentist licensed under the provisions

of the Medical Practice Act on the medical staff of a licensed hospital, whether diagnosis or treatment is rendered at the office

of physician or the hospital, I shall be liable and agree to pay all costs and expenses incurred in connection with such

medical/dental services rendered. This authority is granted only after a reasonable attempt has been made to contact me or

the provided Emergency Contact in a life-threatening situation. _________ (Initial)

5. T

RANSPORTATION

ELEASE AND

AIVER

I give permission for my child to be transported to and from camp-sponsored activities in a camp, church, staff, volunteer,

private, or rental vehicle. I realize there are some dangers involved in transporting children to their activities; therefore, I

specifically waive any claims I may otherwise have against the camp, its leaders, staff, elders, employees, members, agents,

vehicle owners, vehicle drivers, trip sponsors, board of trustees, and any other parties volunteering on behalf of the camp.

Should it be necessary for my child to return home due to the medical reasons, misconduct or otherwise, I shall assume all

transportation costs. _________ (Initial)

6. D

ISCIPLINE

ELEASE AND

UTHORIZATION TO

ETURN

HILD

In the event of inappropriate conduct by my child, I authorize the group leader or staff to send my child home at my expense

from any Camp Como events/activities. _________ (Initial)

7. P

ERSONAL

ELONGINGS

ELEASE

I realize that Camp Como is not responsible for my child’s personal belongings or lost or stolen items.

_________ (Initial)

8. E

LECTRONIC AND

HOTO

IDEO

ELEASE

I give permission to have my child’s photograph/video taken at any Camp Como event and to use the photo/video for any of

the following, but not limited to: appearance in a video/digital picture to be used in a multimedia presentation or an Internet

web page and/or appearance in a picture/video to be used in a publication. _________ (Initial)

I have read and agree to all of the above provisions.

Signed: _____________________________________________________ Date: ____________________

(Parent/Legal Guardian)

Rev. 2/15

Sample Camp Release Form Page 2

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