Surf City 2024 Medication Amendment Form

Surf City 2024 - Medication Amendment
Please take your time filling this out fully and accurately.
You Are A(n)*

Adult leader (18+)Parent/guardian of a camper
Identification Verification.

This form is to be completed by an ADULT LEADER for themself or by a PARENT or GUARDIAN on behalf of their camper. If you are a parent or guardian, you'll fill in your camper's info in a bit. I know, I know, you've filled this out before, but we need to verify your identity to process any changes to you or your camper's medications.
Your Full Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Birthdate*

MonthDayYear
Date
Which Surf City camp are you or your camper attending?*

Camp 1: July 21-26 (High School)Camp 2: July 28-August 2 (Middle School)Camp 3: August 4-9 (Middle School)
What Group (Church, Youth Group, Ministry, etc) are you or your camper coming to camp with?
Camper's Information

Awesome! We're excited to host your camper soon! Please let us know who they are by filling out this section.
Camper's Full Name*

First NameLast Name
Camper's Birthdate*

MonthDayYear
Date
Camper's Grade (entering)*

6789101112Other
Camper's Gender*

FemaleMale
Camper's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Update Medications

Add any medications you or your camper have started taking since you initially filled out your camp paperwork.
Medications

For camp licensing purposes, we consider "medication" to mean any medications, including medications/supplements that do not require prescriptions.
Please note that all medications coming to camp MUST be in their original labeled container.
Medication 1 Name*
Medication 1 Dosage*
Medication 1 Dosage Unit*
Medication 1 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 1 Instructions*
Add Another Medication?*

YesNo
Medication 2 Name*
Medication 2 Dosage*
Medication 2 Dosage Unit*
Medication 2 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 2 Instructions*
Add Another Medication?*

YesNo
Medication 3 Name*
Medication 3 Dosage*
Medication 3 Dosage Unit*
Medication 3 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 3 Instructions*
Add Another Medication?*

YesNo
Medication 4 Name*
Medication 4 Dosage*
Medication 4 Dosage Unit*
Medication 4 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 4 Instructions*
Add Another Medication?*

YesNo
Medication 5 Name*
Medication 5 Dosage*
Medication 5 Dosage Unit*
Medication 5 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 5 Instructions*
Add Another Medication?*

YesNo
Medication 6 Name*
Medication 6 Dosage*
Medication 6 Dosage Unit*
Medication 6 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 6 Instructions*
Add Another Medication?*

YesNo
Medication 7 Name*
Medication 7 Dosage*
Medication 7 Dosage Unit*
Medication 7 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 7 Instructions*
Add Another Medication?*

YesNo
Medication 8 Name*
Medication 8 Dosage*
Medication 8 Dosage Unit*
Medication 8 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 8 Instructions*
Add Another Medication?*

YesNo
Medication 9 Name*
Medication 9 Dosage*
Medication 9 Dosage Unit*
Medication 9 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 9 Instructions*
Add Another Medication?*

YesNo
Medication 10 Name*
Medication 10 Dosage*
Medication 10 Dosage Unit*
Medication 10 Administration Time*

BreakfastLunchDinnerBedtimeOther
Medication 10 Instructions*
Have you listed accurate names, dosages, and administration times/instructions for these medications?*

YesOther
Additional Notes for Camp Health Officer
Statement of Consent and Authorization for Treatment
For Parent/Guardian
I hereby give consent for the following:

The child listed above may be transported by the Grace Adventures, PKF and Grace Adventures staff, including for the purposes of obtaining emergency medical care, to and from Grace Adventures facilities and other locations used by the PKF and its related entities; the child listed above may participate in mud activities; pictures and videos of the child listed above may be taken in conjunction with Grace Adventures and PKF activities and events, and the images taken and such child’s likeness may be used in Grace Adventures and PKF promotional materials. I agree that I and the child listed above will abide by camp rules.

I, on behalf of myself and the child listed on this form, understand that we may be involved in activities, including but not limited to, team building, academic and religious activities, playing with toys and other games, playing on playgrounds, fields, courts, and other recreational areas, running, tumbling, gymnastics, hiking, swimming and other aquatics, boating, water skiing, canoeing, tubing, horseback riding, kayaking, ropes courses, mountain and BMX biking, arts and crafts, team sports, drama and acting, singing and music, social environments and engagement with other youth, preparing and consuming food, and other educational and physical undertakings and social interactions (the "Activities and Programs"). Please also visit www.pittsburghkidsfoundation.org and the web page for each camp to learn more about the types of Activities and Programs in which your child may participate and/or to which your child may be in close proximity.

I understand that this waiver binds me and my child, as well as my heirs, executors, administrators, legal representatives, and assigns, for the benefit of the PKF, its officers, directors, employees, representatives, funding sources, related entities, volunteers, and/or other agents ("Released Beneficiaries"). In exchange for participation in the Activities and Programs, I agree to the following: (a) I agree to prepare my child to take all safety precautions and to abide by camp rules while participating in the Activities and Programs; (b) I understand that my child may be exposed to both physical and non-physical risks, and I agree that I and my child are voluntarily assuming those risks and participating in the Activities and Programs with knowledge that injury to my child or others, including possibly sustaining severe injuries, and even death, may result; I assume full responsibility for physical and non-physical injuries, illnesses, accidents, including death, to my child; (c) I agree that, in the event that my child is physically injured, emotionally harmed, or otherwise requires emergency care, I hereby give permission to the medical personnel selected by my child’s youth leader, or the Grace Adventures, PKF and Grace Adventures staff to give routine non-surgical care, order x-rays, routine tests and treatment, to release any records necessary for insurance purposes and to provide or arrange related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by my child’s youth leader, or the Grace Adventures and PKF staff to secure and administer treatment, including hospitalization, for the person named above. The completed forms may be photocopied for trips out of camp. I release the Released Beneficiaries from all liabilities for all damages, expenses, claims, judgments, actions or causes of action as a result of any loss or injury, to person or property, which I or my child may sustain or suffer during or arising out of participation in the Activities and Programs, whether or not caused by the Released Beneficiaries, and any related medical/allergic conditions.

My signature below affirms that I have read this document, understand it, and agree that it will be binding on me and my child.
By signing my name in the box below, intending for it to serve as my electronic signature hereto, I affirm that I am the legal parent/guardian of the student, have read this entire Health Consent and Release Form, understand it, and agree that it will be binding on my child and me.*

Clear
For Adult Leader
I hereby give consent for the following:

I may be transported by the Grace Adventures and PKF staff, including for the purposes of obtaining emergency medical care, to and from Grace Adventures facilities and other locations used by the PKF and its related entities; I may participate in mud activities; pictures and videos may be taken in conjunction with Grace Adventures and PKF activities and events, and the images taken and such likeness may be used in Grace Adventures and PKF promotional materials. I agree that I will abide by camp rules.

I understand that I may be involved in activities, including but not limited to, team building, academic and religious activities, playing with toys and other games, playing on playgrounds, fields, courts, and other recreational areas, running, tumbling, gymnastics, hiking, swimming and other aquatics, boating, water skiing, canoeing, tubing, horseback riding, kayaking, ropes courses, mountain and BMX biking, arts and crafts, team sports, drama and acting, singing and music, social environments and engagement with other youth, preparing and consuming food, and other educational and physical undertakings and social interactions (the "Activities and Programs"). Please also visit www.pittsburghkidsfoundation.org and the web page for each camp to learn more about the types of Activities and Programs in which you may participate and/or to which you may be in close proximity.

I understand that this waiver binds me, as well as my heirs, executors, administrators, legal representatives, and assigns, for the benefit of the PKF, its officers, directors, employees, representatives, funding sources, related entities, volunteers, and/or other agents ("Released Beneficiaries"). In exchange for participation in the Activities and Programs, I agree to the following: (a) I agree to prepare myself to take all safety precautions and to abide by camp rules while participating in the Activities and Programs; (b) I understand that I may be exposed to both physical and non-physical risks, and I agree that I am voluntarily assuming those risks and participating in the Activities and Programs with knowledge that injury to me or others, including possibly sustaining severe injuries, and even death, may result; I assume full responsibility for physical and non-physical injuries, illnesses, accidents, including death, to myself; (c) I agree that, in the event that I am physically injured, emotionally harmed, or otherwise requires emergency care, I hereby give permission to the medical personnel selected by my trip leader, or the Grace Adventures and PKF staff to give routine non-surgical care, order x-rays, routine tests and treatment, to release any records necessary for insurance purposes and to provide or arrange related transportation for myself. The completed forms may be photocopied for trips out of camp. I release the Released Beneficiaries from all liabilities for all damages, expenses, claims, judgments, actions or causes of action as a result of any loss or injury, to person or property, which I may sustain or suffer during or arising out of participation in the Activities and Programs, whether or not caused by the Released Beneficiaries, and any related medical/allergic conditions.

My signature below affirms that I have read this document, understand it, and agree that it will be binding on me.
By signing my name in the box below, intending for it to serve as my electronic signature hereto, I affirm that I have read this entire Health Consent and Release Form, understand it, and agree that it will be binding on me.*

Clear
Should be Empty:

Surf City 2024 - Medication Amendment

Identification Verification.

Camper's Information

Update Medications

Medications

Statement of Consent and Authorization for Treatment

For Parent/Guardian

For Adult Leader