Young Adults History Form

Young Adults History Form

For any attendee of Summer Camp.
This form is required for anyone attending the Young Adults Retreat.
Name*

First NameLast Name

Dietary Restrictions
Do you have any dietary restrictions?*

YesNo
Please explain.*
Our chef is capable of providing for most allergy-related dietary restrictions.

Insurance Information
Family Doctor Name*
Name of Pediatrician
Family Doctor Phone Number*
Please enter a valid phone number.
Do you have medical insurance?*

YesNo
Full Name of Policy Holder*
Policy Holder Phone Number*
Please enter a valid phone number.
Employer Name (if insured through company)
Insurance Company / Plan Name*
Insurance Company Phone Number*
Please enter a valid phone number.
Health Insurance Policy Number*
Insurance Group Name or Number*

Waivers & Consent
Medical Waiver (must read)

This health history is correct and accurately reflects the health status of the individual to whom it pertains. The person described has permission to participate in all camp activities except as noted above and/or by an examining licensed medical professional. I give permission to the licensed medical professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the individual for both routine health care and in emergency situations, including distributing over-the-counter medications. If I cannot be reached in an emergency, I give my permission to the licensed medical professional to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the individual. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of the described individual’s health record from providers who treat them and these providers may talk with the program's staff about the described individual’s health status.
Checking this box confirms that you have read the Medical Waiver, that you understand it, and that you agree to be bound by it.*

I agree to the above statement.
Media Wiaver (must read)

Full permission and authority is granted to Happiness Is Camping, Inc. and its representatives to photograph or video the camper and to use, publish, and release for publication such as photos, videos, etc. relating to the program of Happiness Is Camping, Inc. The name of such persons photographed may be used in connection with the above, with the understanding that there will be no exploitation of the camper and that any photographs used should conform to standards of good taste. Third-party groups providing programs/services at Happiness Is Camping may use photos/videos of campers with express written consent of Happiness Is Camping, Inc. and must abide by the above.

I hereby release and discharge Happiness Is Camping, Inc. and its Board of Directors and any and all other parties in interests from all claims, demands, grievances, and causes of action of every kind whatsoever, including but not limited to, all liability for damages of every kind, nature, or description which may arise from or out of any injury incurred by my child(ren)/ward while in attendance at the camp or enroute to or from the camp.
Checking this box confirms that you have read the Media Waiver, that you understand it, and that you agree to be bound by it.*

I agree to the above statement.
Assumption of Risk and Liability Waiver (must read)

I understand that part of the camping experience involves activities and group living arrangements and interactions that may be new to me, and that they come with certain risks and uncertainties beyond what I may be used to dealing with at home. I am aware of these risks, and I am assuming them on my behald. I realize that no environment is risk-free, and so I recognize the importance of abiding by the camp’s rules and will obey them.

It is agreed that any dispute or cause of action arising between the parties, whether out of this agreement or otherwise, can only be brought in a court of competent jurisdiction located in Warren Country, New Jersey, and shall be constructed in accordance with the laws of New Jersey.”
Checking this box confirms that you have read the Assumption of Risk and Liability Waiver, that you understand it, and that you agree to be bound by it.*

I agree to the above statement.
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Signature*

Clear
Should be Empty:

Young Adults History Form

Allergies

Dietary Restrictions

Health History

Insurance Information

Waivers & Consent

Medical Waiver (must read)

Media Wiaver (must read)

Assumption of Risk and Liability Waiver (must read)