2024 Camp LIGHT Special Needs Social Event

Come hang out with us at Camp LIGHT's special needs social event! Enjoy meeting new friends, playing games, listening to music, karaoke, and more! This event is open to individuals with medical, physical, and behavior needs.

Teen time is from 1-3pm (ages 13-17)

Adults from 4pm-6pm.

We will have light refreshments.

Participant Name

First NameLast Name

Time attending:

Participant is between 13 and 17 years old and is attending from 1pm-3pmParticipant is 18+ years old and is attending from 4pm-6pm

Parent/Guardian Information/emergency contact info

Name

First NameLast Name

Primary Contact Number

E-mail

example@example.com

We will have volunteers supervising the participants during the event. If the participant has a one on one need and would benefit from a parent/guardian attending with them, please let us know.

The participant will work well in a group setting with supervisionThe participant needs one on one assistance and will have someone attending with them. (please add the name of the attendee in the "other info" section).

Medical needs: Does the participant have any medicines that need to be taken while at the event? Any food allergies or other allergies? Mobility needs? Toileting needs? Any other info we should know?

Behavior needs: Is the participant able to follow simple step rules and directions? Will the participant stay with the group? Do they have a recent history of disciplinary issues in similar settings? Are there any sensory needs or behavior triggers we should be aware of? Any other info we should know?

Is there any additional information that you think would be beneficial for us to know to ensure the participant has a safe and fun time at this event?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Camp LIGHT during the Camp LIGHT social event. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Camp LIGHT and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of participating in the event. I understand that photos may be taken during the event for social media and give consent for my child to be photographed.

Medical Release and Authorization

As Parent and/or Guardian of the named participant (or participant representing yourself if over 18 without a legal guardian), I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the participant's life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named participant. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact the emergency contact person in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach the emergency contact person.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the participant, in my absence.

Date

Signature

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.