Informed Consent, Medical Release, and Authroization
PLEASE READ THE ENTIRE AGREEMENT CAREFULLY BEFORE SIGNING AND DATING
A. I hereby grant permission for my child to attend and participate in activities at the Table Rock Youth/Kids Camp at Table Rock Retreat and Conference Center”(TRRCC)”. I am aware that my child might be photographed or recorded (audio and/or video) and I authorize TRRCC to use such photographs and recordings in training or promotional materials at any point in the future. I understand that I will not receive compensation for the use of such photographs and/or recordings. I also authorize the use of my name in connection with these photographs and recordings.
B. Permission is hereby granted to TRRCC and Table Rock Youth/Kids Camp Staff or on site nurse to proceed with any medical or minor surgical treatment, x-ray, and/or examination deemed necessary for the well-being of the above named participant.
We understand that in the event of serious injury or illness, the attending physician or anyone he/she designates, will make every attempt to contact me in the most expeditious manner possible. If unable to contact me, permission is hereby granted for treatment/or procedures deemed necessary for the well-being of the above named participant.
While participating in any TRRCC program or activity, we expressly authorize all physicians and/or medical facilities that render treatment to the above named participant to release copies of their records to TRRCC.
I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental, or medical. I further agree that in giving this permission and authorizationTRRCC does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel for trips out of camp.
I give permission to TRRCC/Table Rock Youth/Kids Camp to seek medical treatment for my child. I authorize the Camp Nurse or Camp Director to act for me according to his/her best judgment in any emergency requiring medical or surgical care. I further understand that I am responsible for the cost of all medical care not covered by the camp medical insurance. I further authorize photographs of my child to be taken and published by the camp unless I have provided written descent.
C. Camp Rules
I understand that the Table Rock Youth Camp has rules and expectations for my protection and to ensure that everyone has an enjoyable camp experience. I understand that failing to follow these rules will result in being picked up from camp by my parent/guardian immediately. I will respect the camp staff and counselors and help them make this a great camp.
1. Respectfully follow directions given by all staff members and counselors.
2. Dress Modestly:
Girls:
a. Shorts/skirts should come below fingertips.
b. One-piece swimsuits only
(or dark t-shirt for cover-up).
c. No strapless shirts/dresses
(3-finger-rule for tank tops)
Boys:
a. Shirts are required.
b. Underwear may not be exposed.
3. Cell phones and other electronics should be left in cabins during the day and used minimally during free-time. If used excessively, with one warning they will be taken until the end of camp.
4. No knives, guns, other weapons, fireworks alcohol, cigarettes, or drugs of any kind. All medications must be submitted and approved by the nurse on registration day.
D. I acknowledge and understand there are inherent risks associated with many camp activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my attendance at a TRRCC camp is a privilege and as a consideration for this privilege, I release TRRCC, including its employees, agents and trustees, from responsibility for my accidental physical injury, including death or illness, and loss of personal property while at camp or during TRRCC sponsored travel to and from camp. This release is also intended to include all claims made by my family, estate, heirs, personal representative or assigns. I grant permission for my child to participate in all special trips off the camp property with proper staff supervision.
E. I hereby voluntarily and forever release, waive all claims against, and discharge TRRCC and its officers, trustees, agents, employees, independent contractors, volunteers, and all other persons or entities acting under their direction and control (collectively “the Released Parties”) from, and agree not to pursue, any and all claims, demands, or causes of action, related to illness, injury, disability, death, property damage or any other loss which is in any way connected with my enrollment or participation in the camp. I further agree to defend, hold harmless, and indemnify (to pay or reimburse for money they are required to pay, including attorney’s fees and costs) the Released
Parties for any and all claims by me, my child, a member of my immediate family, a rescuer, another participant, a medical care provider, or any other person, arising in whole or in part from illness, injury, disability, death, or any other loss suffered by me or caused by me in connection with my enrollment or participation in the camp. These release and indemnity agreements are to be construed to provide release and indemnity to the fullest extent permitted by law; the release and indemnity agreements apply to claims that a Released Party was in whole or in part negligent. But, the release and indemnity agreements do not apply to any Released Party to the extent that Released Party is determined to be grossly negligent or to have caused harm intentionally.
Although TRRCC has taken reasonable steps to provide me with appropriate equipment and skilled staff for the offered activities so I can participate in an activity for which I may not have experience, I acknowledge that this activity is not without risk. Certain risks cannot be eliminated without destroying the unique character of the experience.
The same elements that contribute to the unique character of this activity can be causes of loss or damage to my equipment, accidental injury, illness, or in extreme cases, permanent trauma, or death. TRRCC does not want to frighten me or reduce my enthusiasm for this activity, but thinks it is important for me to know in advance what to expect and to be informed of the inherent risks.
F. I have read, understood and voluntarily agreed to the terms of this agreement. I understand that I am waiving certain legal rights in this document, and agreeing to provide indemnity. I acknowledge that this agreement shall be effective and binding upon me, my heirs, assigns, personal representative and estate. I represent that I am of the age of majority and able to enter into this contract; if not, I will have my parent or legal guardian sign below.