Camp Overbrook 2024: Emergency Contact, Waiver & Photo Release Forms

Emergency Form - Camp Counselors

Deaf Apostolate

222 North 17th Street, 8th Floor

Philadelphia, PA 19103

Please fill out this page. Please complete the online form, scan printed form to CampInSign@archphila.org, mail to the Deaf Apostolate or bring to the Camp Overbrook Staff meeting. Please print clearly.

Select One:*

Adult 21 or olderYoung Adult (in college)

Name*

Date of Birth*

Address*

Address

Street Address Line 2

CityStateZip

Cell Phone*

Email*

example@example.com

Emergency Contact Name*

Emergency Contact Phone Number*

Health Insurance Co*

Policy

Group

Physician

Medications currently taken (prescription and non-prescription) and include dosage:

Allergies

Can this person be given aspirin by the medical coordinator?*

YesNo

Can this person be given acetaminophen by the medical coordinator?*

YesNo

Can this person be given ibuprofen by the medical coordinator?*

YesNo

In case of a Medical Emergency I understand that, in the event medical treatment is required, every effort will be made to contact me or the emergency contact person. However, if I cannot be reached, I give permission to the staff to secure the services of a licensed physician to provide the care necessary, including hospitalization, anesthesia, injection, or surgery for my child's well-being. I hereby agree to indemnify and hold harmless the Deaf Apostolate, the Archdiocese of Philadelphia and its officers, employees, and volunteer staff from any liability.

Print First and Last Name of Participant*

Adult Signature*

Date*

Date

LIABILITY FORM FOR ADULT LEADERS AND ADULT ASSISTANTS

Camp Overbrook: IN SIGN 2024

Deaf Apostolate of the Archdiocese of Philadelphia

WAIVER OF LIABILITY AND ASSUMPTION OF RISK Part A

Saint Joseph's University

To participate in Camp Overbrook: IN SIGN at SJU all participants must sign Part A:

I desire to voluntarily participate in the Event operated by the Deaf Apostolate, Archdiocese of Philadelphia ("Registrant") that will be held on June 17-28, 2024 (the "Event") at Saint Joseph's University ("University" I hereby warrant and represent that I do not have any medical condition or physical limitation that would put me at risk for injury as a result of my participation in the Event. In consideration of my voluntary participation in the Event and my use of University's facilities, (i) I hereby assume all risks of injury which may result from my participation in the Event and my use of University's facilities, and (ii) I agree, on behalf of myself and my heirs, executors, administrators, and assigns, to waive, indemnify, hold harmless, release and discharge University, its affiliates, and its respective officers, trustees, directors, employees, agents, successors and assigns from any and all claims, damages, demands, rights of action or cause of action, present or future, known or unknown, anticipated or unanticipated, resulting from, or arising out of, my participation in the Event, and my use of University's facilities. I agree to abide by all of the rules and regulations of University in effect during my participation in the Event. I understand that University is not affiliated with Registrant and that University is not a sponsor or co-sponsor of the Event, but is merely allowing Registrant to use its facilities for the Event. I have read and understand the foregoing and affirm that I am participating in the Event of my own free will.

Print First and Last Name of Participant*

Signature of Participant*

Date*

Date

Photo Release Form - Camp Overbrook: In Sign 2024 - Part B

It is helpful to us if you sign Part B SO that we do not need to screen the pictures we use for brochures, newsletters or on our website.

We are requesting your permission for the use of pictures or video of those participating in the programs sponsored by the Deaf Apostolate, whenever such pictures or video are used in the form of publication or viewing approved by the Deaf Apostolate (ex: promotional video or brochure about camp).

I hereby give the Archdiocese of Philadelphia, its successors and assigns and those acting with it authority, the unqualified right and permission to reproduce, copyright, publish, circulate or otherwise use any pictures or video of me produced by the Archdiocese of Philadelphia or its designates.
I also give permission for my name to be used in conjunction with pictures or films whenever approved by the Deaf Apostolate.
I give my permission for picture or video, without name, to be posted on a website or social network page associated with the Deaf Apostolate of the Archdiocese of Philadelphia.
I fully understand that this is a complete release of all claims against the Archdiocese of Philadelphia or any other person, firm or corporation by reason of such use of pictures or films.

Print First and Last Name of Participant*

Signature*

Date*

Date