Summer Camp Registration Permission And Medical Release Form (Page 2 of 2) in pdf

___ Help during a Camp (Please indicate below which camp(s) you are requesting a scholarship to attend and can volunteer for)

____________________________________________________________________________________________________

___Help with clean-up after Camp (Please indicate below which camp(s) you are requesting a scholarship to attend and can help

with clean-up) ________________________________________________________________________________________

___ Prayer Partner (I am unable to volunteer to help with a camp but can be a St. James Prayer Partner) Please provide email

address for contact regarding being a St. James Prayer Partner_________________________________________________

____ **I am not requesting a scholarship, but would like to volunteer to help with a camp(s):

___________________________________________________________________________________________

Each family will receive either a call or an email letting you know that your child(ren) has/have been registered. You will also receive a call or email

if you request a scholarship letting you know if we were able to grant the scholarship request. (Please send any questions to or

call 304-725-5558 x231.)

Part II: Permission and Medical Release (Minors Under 18)

In consideration of the opportunity for my son/daughter to participate in this program, I agree to RELEASE AND HOLD HARMLESS AND

INDEMNIFY the Roman Catholic Parish of St. James the Greater, 49 Crosswinds Drive, Charles Town, WV 25414; the Roman Catholic

Bishop of Wheeling-Charleston and his successors, a Corporate Sole; and all their agents, servants, and employees from any and all liability,

claims, demands, and causes of action arising out of or relating to any loss, damage, or injury sustained in connection with or arising out of my

son’s/daughter’s participation in the program.

I hereby grant permission to any staff to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the

event I cannot be reached.

(Check one of the following):



I am covered by hospitalization and medical insurance under policy # ____________________________________ issued by

_________________________________________________.



I do not have medical coverage and assume full responsibility for the cost of hospitalization and medical care for my

son/daughter.

I hereby grant permission to any staff person to provide the following over-the-counter medication to my son/daughter if requested by my

son/daughter (circle all that apply):

TylenolBenadrylAdvilSudafedMidolKaopectateNeosporinPepto-BismolAspirin

Please note any other medical information concerning medication, allergies, disability, illness, etc.

____________________________________________________________________________________________________

Please note any dietary restrictions:

____________________________________________________________________________________________________

Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites, or other

materials produced from time to time by the Roman Catholic Parish of St. James the Greater (participants would not be identified, however,

without specific written consent).

Parents/guardians who do not wish their child(ren) to be photographed or filmed should so notify the parish in writing. Please note that the

parish has no control or responsibility over the use of photographs or film taken by media that may be covering the event in which your

child(ren) participate(s).

We reserve the right to refuse and/or rescind acceptance of any registration or camper at any point if we believe he/she is unsuitable for our programs for any

reason including: health, physical ability, or behavioral history.

Parent/Guardian Signature:_____________________________________________________________Date: __________________________