• DeMolay Leadership Camp 2022 Staff Registration

    Camp Sheppard, WA
  • Staffer Information

  • Medical Release and Authorization

    As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

    Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

    Permission is also granted to the  Pacific Northwest DLC, and its affiliates to provide the needed emergency treatment prior to the child’s admission to the medical facility.

    Release authorized on the dates and/or duration of the conference.

    This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

  • Confirmation

    BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

  • Thank you {name5},

    Once you are ready to submit your payment you can return to use the PayPal option, by coming back to the website and selecting the "payment option" button, or if you are planning to submit a check you can send it to:

    PNW DLC 2022
    c/o Warren Cole - Registrar
    20040 NW Nestucca
    Portland, Oregon 97229

  • Should be Empty: