• Pathways to Healthcare Practice

    Pathways to Healthcare Practice

  • If you have any questions as you navigate this form, please email Renee Brown at [email protected].

  •  To register, select the camp(s) you will attend:

  • Participant Information

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  • We are asking about participant medical information for the sole purpose of caring for the participants and in case of emergency.

  • Participant Health Information


  • Parent or Guardian and Emergency Contact Information

    Please note: the individuals listed in the section below will also be authorized to pick-up your child from camp.

  • Parent or Guardian


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  • Emergency Contact

    This is to be someone OTHER than the legal guardian(s) listed in the above section. In case of an emergency, after attempting the parent and legal guardian phone numbers, we will contact the following additional names you have authorized to act on your behalf in case of emergency.

  • Pick Up Authorization

    Parents, Guardians, and Emergency Contacts listed in the above section will be authorized to pick-up your child from camp. If you would like to authorize any additional individuals for pick-up, please identify these individuals in the section below. Individuals authorized to pick-up must be at least 18 years old and may be asked to provide a photo ID to camp staff. The individuals listed below are authorized to pick up your child from the camp at any time.

  • Other than the parent/legal guardians and the emergency contacts listed on this form, who else would you like to authorize to pick-up your child?

  • PAYMENT

     No refunds for individuals who register after May 12th, 2025

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    • Belmont University Camp Registration Parent/Guardian Release and Authorization

    • Camp: June 2-June 6: Pathways to Healthcare Practice
      Participant Name(s):

      Participant 1 Legal Name: * Preferred Name:  *   
         

      Assumption of Risk and Release


      Release For the purposes of this document, the term “participant” shall refer to each individual listed in the Participant Name(s) section above.


      In consideration of the participant being permitted by Belmont University to participate in any camp for which the participant is registered for on Belmont’s campus, I voluntarily grant permission for the participant to participate in the camp activities and I, with full knowledge and appreciation of the potential risks and hazards, assume all responsibility and risk of the participant’s participation including all risk of loss of limb or life, property damage or injury to others.

      I understand that the camp may include activities including but not limited to: vigorous physical exercise including running and jumping, transportation to and from activities, and group recreation activities.

      I recognize that there are risks and hazards directly or indirectly involved, making these and related activities potentially dangerous and I represent and warrant the participant is in good physical condition and is able to safely participate in camp activities.

      I, on behalf of myself, the participant, our family, heirs and legal representatives release Belmont University, its students, agents, employees, officers and trustees, from any liability for damage or loss to participant’s person or property which may arise out of participant’s participation in the camp.

      I grant permission for Belmont University, its agents or employees to obtain necessary medical attention in case of sickness or injury of the participant. I consent to any necessary medical examination, diagnosis or treatment and agree to be responsible for the costs associated with such medical services. I understand that while the university will attempt to utilize a preferred provider when possible, the university may choose to use another provider when the university, in its sole discretion, determines such action is necessary in an emergency.

      Photo and Video Release

      I understand that Belmont University may take photographs or video images of camp activities which may include the participant.

      I hereby give Belmont University, its employees, licensees, and agents, the absolute and irrevocable right and permission with respect to photographs or video images taken of the participant or in which the participant may be included with others to:
      • copyright the photograph/video/audio footage in the university’s name or university photographer/videographer’s name; and
      • use, re-use, publish and republish the same in whole or in part, individually or in conjunction with other photographs/footage, in any medium, including broadcast over the Internet, for instructional and promotional use of the university.

      I hereby release and discharge Belmont University, its trustees, officers, employees, licensees and agents from any and all claims and demands arising out of or in connection with the use of the photographs or video footage, including all claims for invasion of privacy and appropriation.

      This authorization and release shall also ensure to the benefit of the legal representatives, licensees, and assigns of Belmont University.

      Pick Up Authorization

      I authorize and release the individual(s) listed on the camp registration form to pick up the participant from camp at Belmont University. I understand that individuals authorized for pick up may be required to present valid photo identification in order to pick up the participant. I understand that individuals not listed as parent, legal guardian, emergency contact, or listed on the authorized pick up list will not be permitted to pick up the participant without express written permission provided to Belmont by a parent or legal guardian in advance.

      Participant Behavior

      Participants enrolled in the camp are expected to follow the rules established by Belmont University for the purpose of safety and smooth operation of the camp. If a discipline problem occurs, the parents/guardians will be contacted by Belmont University. Belmont University reserves the right to end a participant’s participation in a camp when the participant’s behavior affects the safety or wellbeing of camp staff or other camp participants.

      Statement of Understanding

      I,   *   (print name), warrant that I am the parent or legal guardian of the camp participant listed above and have the authority to complete this camp registration on behalf of the participant.

      I have completed the registration information online to the best of my knowledge. I am fully informed of the contents of the Assumption of Risk and Release, Photo and Video Release, Pick Up Authorization instructions, and Participant Behavior Policy and I agree to be legally bound by their terms.

      Signed, 

      Name: *   Sign Name:*   Date:Pick a Date*    

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