Explore 2023

Coda Explore will have some faith content. (For example, morning exercises and the closing session may have Christian songs or lessons from the Bible on love, respect, integrity etc.) Faith content will be non-sectarian and not be connected to any particular denomination*

I am aware that Coda Explore will have some faith content

Photo Waiver: Understanding that Coda photos and videos are important to promote public awareness, access future scholarship funding and reach more youth, I hereby consent for my child (or myself if 18 or older) to be photographed and/or videoed for Coda Mountain Academy. The resulting photographs or videos may be subsequently used without compensation to me by Coda Mountain Academy, or third parties for publications (including web sites,) advertising, facebook and/or publicity purposes at the discretion of Coda Mountain Academy. Some photos and videos may be used in the year end grant report. I waive the right to inspect or approve the finished photograph, video and/or publication use.*

I, parent or guardian, consent to the above stated photo/video waiver for Coda.I, parent or guardian, DO NOT consent to the above stated photo/video waiver for Coda.
Allergies/Prescription Medications?*

YesNo
If yes, Please List them Here
Any medical problems and/or medications that we should be aware of:*

YesNo
If yes, Please List them Here
Emergency Contact other than parent/guardian (This will only be used if parent/guardian cannot be reached)*

First NameLast Name
Relationship to the Student*
Emergency Contact Phone Number (if we cannot reach you)*
Medical Release & Liability Waiver

I, the undersigned, am the parent or legal guardian of this minor and have given my consent for him/her to participate in activities hosted by Coda Mountain Academy. In the event of injury, accident, illness or other emergency while participating in the camp, I consent to any reasonable medical treatment as deemed necessary by a licensed physician, emergency medical technicians, nurses, and laboratory technicians. In the event any treatment is required, which a physician and/or hospital personnel refuses to administer without my consent, I hereby authorize Esther Morey, Robert Morey, Jessica Moneypenny, Eric Snuffer, or an associated adult supervisor to give such consent for me, if I cannot be reached by telephone at one of the numbers listed above, or because of an emergency in which there is no time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for me, I agree to hold such person, other associated adults and Coda Mountain Academy free and harmless of claims, demands, or suits for damages which may arise from the giving of such consent. I also acknowledge that I accept to be ultimately responsible for the cost of any medical care whether or not the cost of that medical care will be reimbursed by my health insurance provider. Further, I affirm that the health insurance information provided in the medical release form is accurate as of this date. I further authorize disclosure of medical information by a treating physician to the camp director or associated adult supervisor as permitted by The Health Insurance Portability and Accountability Act of 1996 (HIPAA). I also understand that although the students will be supervised by Coda Mountain Academy staff, I do assume the risk in my student’s participation in the event and transportation to and from the event if applicable. I acknowledge that I will not seek to have Coda Mountain Academy held liable in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of my son’s/daughter’s participation in the field trip.This release of liability includes accident, injury, loss, or damages to the student, as well as, to other individuals or property which may result from the student’s participation in the event. I hereby release and agree to hold harmless Coda Mountain Academy, its officials, agents and employees, from any claims arising out of my son’s/daughter’s participation in this event.
*

I have read and understand and accept all of the statements recited above and accept full responsibility as described.
Signature*

Clear
Date

MonthDayYear
Date
Questions, Comments, or Concerns
For additional questions or comments, please call us at our Coda Hotline 304-900-0096 or contact us online at www.codamountain.com or on our Facebook page

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Coda Explore 2023

Basic Info

Transportation

Medical Release & Liability Waiver