Summer Camp Activity Waiver Form

Maryvale Farm Camp Waiver Form
Name of the Child*

First NameLast Name
Name of the Parent/Guardian*

First NameLast Name
Parent/Guardian's Phone Number
Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which program did you sign up for?*

June 9-13June 16-20June 23-27July 7-11
Do you consent to the administering of Benadryl to your child in the case of an allergic reaction to a bee sting (only when necessary and with clear signs of a reaction)?

YesNo
Statement of Consent & Waiver

I hereby agree and declare that I am the legal parentguardian of the above-named child and hereby consent to the child's participation in Maryvale Farm Summer Camp 2025. I understand that participation in this camp may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in this camp.

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to camp supervisor(s) to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s). This includes the performance of first aid and CPR, or recieving emergency medical treatment by a paramedic, first responder, pediatrician, or emergency room physician and if necessary transportation via ambulance to the emergency room.

I, the parent/guardian, hereby agree and declare that I have carefully read and understand the scope of the summer camp activities and I consent to the participation of the above-named child to these activities.

Any type of injury that may occur to the child without the fault of the camp management and activity supervisors, the camp management cannot be held responsible for any harm that may occur to the child without the fault of the camp management and activity supervisors.
Parent/Guardian Signature*

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Maryvale Farm Camp Waiver Form