Waiver, Indemnification, And Medical Treatment Authorization Form (Page 2 of 3) in pdf

CONSENT TO PARTICIPATE

I, or we, parent(s) or guardian(s) of a minor child named ___________________________________________ do hereby give

consent for said minor child to participate in all activities other than swimming, kayaking, sailing, canoeing or Challenge Course

activities scheduled as part of the District 8 4-H County Camp. Activities include riflery, archery, initiative games, crafts, and

environmental education. Children will be attending parties, ceremonials, and other activities during their stay.

PLEASE CHECK AND INITIAL THE APPROPRIATE RESPONSE IN THE FOLLOWING SECTIONS:

Swimming, kayaking, canoeing and/or sailing activities: I/we do further give consent for said minor child to participate in

organized swimming, kayaking, canoeing and/or sailing activities conducted at 4-H Camp. I/we understand that said minor child

shall be required to take an approved swimming skill level test and will be assigned to that portion of the swimming area which is

commensurate with his or her demonstrated swimming ability. An approved swimming skill level test will also be required before

said minor child can participate in canoeing, kayaking or sailing program. Participants will be required to wear Personal Floatation

Devices at all times during participation in canoeing, kayaking and/or sailing activities.

_____ Yes _____ No

Challenge Course activities: I/we do further give consent for said minor child to participate in organized activities on the Challenge

Course. I/we understand that said minor child will be supervised and instructed in these events by an individual who has been

certified and trained to facilitate this level of programming. All participants are provided instruction on the wearing and use of

safety equipment prior to participation.

_____ Yes _____ No

Media Release: In the event photographs, slides, or video tapes are made of said minor child, I/we consent to the release of those

photographs, slides or video tapes for use in promoting 4-H programs.

_____ Yes _____ No

Field Trips: I/we do further give consent for said minor to participate in scheduled field trips during this program. I/we understand

that only approved adult volunteers and/or staff will transport said minor off the campgrounds and will serve as a chaperone for

the field trip.

_____ Yes _____ No

Further, I/We do hereby authorize the County 4-H

Further, I/We require that said minor child NOT be released

Camp staff to release said minor child to the following

to the following person/people at the conclusion of the

person/people at the conclusion of the activity: (please

activity:

list all persons, including parents):

Signature of Parent/Guardian

Date

Page 2 of 3

Waiver, Indemnification, And Medical Treatment Authorization Form Page 2