Fillable Student Emergency Contact Information (Page 2 of 2) in pdf

AGREEMENT & RELEASE OF LIABILITY STATEMENT

REQUIRED -- Please complete this form and bring to first day of camp.

I hereby grant permission for my child(ren) to participate in the Annmarie summer camp program as described, including the

activities for which my child(ren) is registered. I understand that Annmarie may deny enrollment to or dismiss at any time

any participant who is considered to be participating inappropriately in the program. I grant Annmarie permission to use any

photographs of my child(ren) taken during the camp for promotional purposes.

I understand and accept the need for Annmarie to be fully informed as to the physical and mental health of my child(ren).

Failure to disclose such essential information at the time of enrollment or upon request of Annmarie may cause for

immediate dismissal. Annmarie will respect the confidentiality of such information.

In the event of an emergency requiring immediate medical treatment, I understand that the staff of Annmarie will try to

reach me by using the telephone numbers listed on the emergency contact form. In the event that I cannot be reached, I

authorize treatment by appropriate medical personnel.

If applicable - In the event that my child should require the use of medication as listed on the submitted

MEDICATION

ADMINISTRTION AUTHORIZATION FORM,

while attending an Annmarie camp, I hereby give my full and unqualified

permission for Annmarie staff or agents to assist or administer the medication, as the case may be. I understand that there

is no nurse or doctor on duty at Annmarie and the Annmarie staff will call 911 and seek medical assistance in such an event. I

do hereby fully release or discharge Annmarie, and its officers, agents, volunteers, and employees from any and all claims

from injuries, damages, and losses I or my child may have (or accrue to me and my child), and arising out of, connected with,

incidental to, or in any way associated with the assisting with administering, or administering the medication.

I am fully aware, understand and acknowledge that my child(ren) will be involved in physical activities, both outside and

indoors, during the camp, including but not limited to hiking on nature trails, outdoor games, playground activities, theater

activities, gardening, studio arts, and arts and crafts that my child will engage in that may result in physical injury. I

understand and acknowledge that these activities have inherent risks associated with them, and I knowingly assume those

risks, release and covenant not to sue Annmarie for any liability whatsoever resulting from my child’s participation in the

activities of the camp.

In consideration of the acceptance of the camper for enrollment in the Annmarie summer camp program, I hereby release

and discharge, as well as indemnify and hold harmless, Annmarie Sculpture Garden & Arts Center, the Koenig Private

Foundation, Inc., Calvert County Government, Calvert County Commissioners, and Ann’s Circle, Inc., (collectively referred to

as “Annmarie”), its agents, employees and officers, from all claims, demands, actions, judgments, and executions which the

undersigned as parents/guardians of the camper, ever had or now has or may have or claim to have against Annmarie, its

successors or assigns, for all personal injuries, known or unknown, and injuries to property, real or personal, caused by, or

arising out of the camper’s enrollment in the Annmarie summer camp program.

Parent/Guardian Printed Name ____________________________________________________________________

Parent/Guardian Signature Date__________________________________________________________________

Student Emergency Contact Information Page 2