Camp Hope Registration

Parent/Guardian Information

Emergency Information (other than parent)

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Abiding Hope Counseling during the therapeutic rehabilitation program. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Abiding Hope Counseling and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said child, I hereby waive all claims against  Abiding Hope Counseling, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball, running, etc.  I understand my child may play on play equiptment that may or may not be owned by Abiding Hope, and understand there is risk of injury during those activities that I do not hold AHC responsible. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.  I also give permission for transportation for my child to and from the program and all of the above assumed risks and waivers apply to transporation as well.

I understand that this is a group program and therefore confidentiality will have it's limitations due to it being group in nature.  I understand that I am not to discuss any other childrens attendance in this program with anyone, including AHC staff unless it is my own child.  

I understand that a counselor from AHC has discussed the risks and benefits of my child participating in this program and I agree to this course of treatment for my child.  i have been informed of the purpose of the program and agree to support my child through active involvement in my childs treatment.  I understand that if my child's behavior poses a threat to other children in the group that they may be dismissed from the program for the safety of others.

I understand that this program goes year round and this consent is not specific to only the summer months, but ongoing throughout the year until I revoke my consent.

I have read and understand Abiding Hope Counseling's company informed consent, privacy policy, and rights and responsibilities as outlined in the intake forms I signed during the intake process for my child.

Waiver of Liability and Hold Harmless Transportation Agreement 

I understand that Abiding Hope Counseling may offer transportation in their personal vehicles, or a rented vehicle with a hired driver.  I am granting permission to travel to and or from any pick up and drop off location in a vehicle or vehicles that are owned or not owned or operated by the company: _____________________________________________________________________ 

1. I hereby release, waive, discharge and covenant not to sue Abiding Hope Counseling, its individual members, officers, agents, servants, policies, or employees (hereinafter referred to as releasees) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by my minor child(ren) or me, or any of the property belonging to me, as result of, or in any way arising out of my child(ren) traveling to and or from locations, in a vehicle or vehicles not owned or operated by Abiding hope Counseling or those owned by Abiding Hope Counseling.

2. I voluntarily assume full responsibility for any risks of loss. 

3. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs due to my child(ren) traveling to and or from any location, n a vehicle or vehicles not owned or operated by the Abiding Hope Counseling. 

4. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed and enforced in accordance with the laws of the state of Kentucky. 

5. In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed. 

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.

Medical Release and Authorization

In the event of a medical emergency, Abiding Hope will attempt to contact the parent/guardian. 

As Parent and/or Guardian of the named child, 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 athlete. 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 Abiding Hope Counseling and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

 

 

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.