Release And Waiver Of Liability And Indemnification

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Camp: __________________________________________ Dates: _________________
Camper: _________________________________________
RELEASE AND WAIVER OF LIABILITY AND INDEMNIFICATION
AGREEMENT
Purpose: To release Ohio Wesleyan University from any and all liability
for the claim(s) of a participating camper and/or the claim(s) of such
camper’s parents or legal guardian that might arise as a result of the camper’s
participation in the summer camp and its programs and activities.
I/We recognize the possibility and risk of injury associated with my/
our child’s participation in the summer camp. In consideration of Ohio
Wesleyan University’s accepting my/our child as a registrant for and
participant in the camp, as the parent/legal guardian of ________________________________________________ date of birth:
____________________, I/we hereby release, discharge and/or otherwise indemnify Ohio Wesleyan University and agree not to seek or to
hold Ohio Wesleyan University responsible, its agents, employees, and the above-named sponsor from any claim(s) by or on behalf of the
camper or myself/ourselves for injuries of any kind, including but not limited to those caused or allegedly caused by the negligence of Ohio
Wesleyan University, its agents, or its employees, as a result of or in connection with the camper’s participation in the summer camp and its
programs and activities.
Signature of Parent/Guardian: ________________________________________________ Date:______________________________
MEDICAL AUTHORIZATION FORM
Purpose: To enable parents and guardians to authorize medical and, or, dental treatment for any participating camper who becomes ill or
injured while in any program or activity in or related to the above-named Ohio Wesleyan University summer camp, when the parents or
guardians cannot be reached.
As the parent/legal guardian of ___________________________________________________ date of birth: _____________________,
I/we request that, in my/our absence, the above-named camper be admitted to any hospital or medical facility for diagnosis and treatment;
and, I consent to such admission, diagnosis, and treatment. I/we request, consent to, and authorize physicians, dentist, and staff, duly
licensed as Doctors of Medicine or Doctors of Dentistry or other licensed technicians or nurses, to perform any diagnostic procedures,
treatment procedures, operative procedures and x-ray treatment of the above minor.
The following apply(-ies) to the above minor child (please check all that apply and leave blank if not applicable):
_____ diabetes
_____ epilepsy
_____ heart condition
_____ hearing loss
_____ vision loss
_____ allergies to:
_____ bee stings
_____ foods (identify)
_____medications (identify)
_____ asthma, Medication prescribed: _______________________________
_____ physical limitations
Date of last Tetanus Booster:______________________________
Any other medical problems which should be noted: __________________________________________________________________
Physician:_________________________________________________________ Phone:_____________________________________
Dentist:__________________________________________________________ Phone:_____________________________________
Name of Parent/Guardian:_______________________________________________________________________________________
Address:_____________________________________________________________________________________________________
City/State/Zip:________________________________________________________________________________________________
Phone (H):_______________________________ (W):______________________________ (Fax):____________________________
Person to be notified if parent/guardian is unavailable:_________________________________________________________________
Phone (H):_______________________________ (W):______________________________ (Fax):____________________________
Insurance Carrier:_______________________________________________ Policy Number:__________________________________
Signature of Parent/Guardian:____________________________________________ Date:___________________________________

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