Camp Meeting 2025 Consent to Treat Form

Consent for Medical Treatment of Minors Authorization Form

2025 Camp Meeting
A separate consent form is needed for each minor child. If you are bringing minors to camp meeting who are not yours, this form must be signed by the parent/legal guardian of each minor in your care, custody, and control during camp meeting. If this form is signed by a legal guardian, a copy of the court order granting that legal guardianship must be attached. Please use blue ink to fill out and sign this form.

In consideration of my child being allowed to participate in camp meeting activities and because I am aware that my child’s participation in those activities may result in the need for medical treatment because of accident or sickness, I, the undersigned parent or legal guardian of First Name* Last Name* , born Date* (birthdate) do hereby consent to any medical treatment and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while my child is under the care of camp meeting children’s department leaders and I am not reasonably available by telephone to give consent. It is further understood that this consent is given in advance of any specific diagnosis or treatment which might be required and is given to authorize the caregiver, or the physician, medical facility, or other medical provider, to render such emergency medical assistance as is deemed necessary in the exercise of their professional judgment. Additionally, I authorize the healthcare provider to discuss in full with my child’s camp meeting children’s department leaders as authorized recipients of my child’s protected medical information any medical information that is required to help the treatment of my child under the Health Insurance Portability and Accountability Act of 1996 and the Indiana Medical Consent Act, I.C. 16-36-1-1, et. seq. I acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on the condition of my child. I assume financial responsibility for such medical care.

This authorization is effective from June 3, 2024 through June 8, 2024.
Children's Department
Please select the department your child will be attending for each meeting. Children may not switch between departments for the afternoon activities. Once registered for a given department, we cannot transfer them during the week. Thank you for understanding.*

PrimaryJunior/EarliteenYouth
Media Release Form

Children who attend camp meeting will be photographed andmay be included in camp meeting highlights our conference publications. Allrights, title, and interest in the photography and media outlets belong to theIndiana Conference and there will be no child or family financial compensationfor the use of any of the photos or media. The Indiana Conference ofSeventh-day Adventists has the sole control to edit, copy, alter, and revisethem. The Indiana Conference of Seventh-day Adventists further retains controlover their use and distribution.
Signature

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Off-Campus Permission Form
I also * my child, First Name* Last Name* permission to participate in this year's off-campus meeting activities as listed on the schedule provided for me. I further understand that my child's participation in such off-campus activities is strictly voluntary and done so at my sole discretion.
Signature*

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printed name of parent or legal guardian:*
today's date*

MonthDayYear
Date
primary emergency contact phone:*
Please enter a valid phone number.
camp meeting lodging location or home*
primary contact email*
example@example.com
Minor's Health Information
minor's full legal name*

First and Middle NamesLast Name
minor's date of birth*

MonthDayYear
Date
home street address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
health insurance policy # and group #*
medications*
allergies*
date of last tetanus shot (if known)
other pertinent medical information

IN Camp Meeting Canter Fun Run
I give my child permission to participate in the Indiana Camp Meeting Canter Fun Run to be held on Friday, June 6, 2025.*
child's age on the day of the race:
I know that running a race is a potentially hazardous activity, and that I should not enter unless I am medically able and properly trained. I agree to abide by any race guidelines. I assume all risks associated with running this event including but not limited to: falls, contact with other participants, weather: including low or high temperatures/humidity, etc., and conditions on the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts and in consideration of your accepting my entry, I myself/or minor I sign for, and anyone entitled to act on my behalf, waive and release the Race Staff, the Seventh-day Adventist Church, Indiana Conference of Seventh-day Adventists, Indiana Academy, the Thrift Store at 24910 STATE ROAD 19, Cicero, IN, and of their employees/volunteers and successors, from any and all claims and liabilities of any kind arising out of my participation in this event or carelessness of the persons named in this waiver.
Please select the race your child will participate in:

Kids' Fun Run (age restricted)3-mile Fun RunBoth
Type your (parent/guardian) name:
Signature

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Today's Date:

MonthDayYear
Date
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Consent for Medical Treatment of Minors Authorization Form

Children's Department

Media Release Form

Off-Campus Permission Form

Minor's Health Information

IN Camp Meeting Canter Fun Run