A. Consent for Attendance and Participation
This information provided in this form is correct and my child has permission to participate in all activities at YMCA Camp Mason (23 Birch Ridge Road, Hardwick NJ 07825) on August 18 - 22, 2025
B. Insurance
I agree to pay any medical bills (independently or through insurance) that may arise as a result of injuries incurred at the LMTI Summer Leadership Conference.
C. Medical Consent
I hereby consent and authorize the LMTI Health Care Staff to administer medication as needed to the participant as indicated by me on this application. I understand that the LMTI Summer Leadership Conference occurs in an outdoor setting and hereby authorize trained LMTI Staff or Health Care Staff to administer first aid to the participant when necessary. In the event of a medical emergency, I understand that I will be contacted as soon as possible and that my child may be transported to Newton Memorial Hospital, or another hospital as may be necessary or otherwise determined. I give permission for the administration of all needed medicines, the performance of all surgical and other treatment, and the administration of any anesthetic or injection which, in the opinion of the attending physician, may be necessary and/or advisable in the event of any medical emergencies regarding my child. It is understood that reasonable efforts shall be made to reach me prior to rendering emergency treatment to the patient. Without limiting the permissions I granted regarding medical treatment and transportation in this paragraph and below, in the event that I am unavailable, I designate the aforementioned emergency contact to provide medical consent on my behalf, or to transport my child to/from Camp Mason or to/from the medical facility.
D. Transportation Consent
I give permission for LMTI staff or volunteers to transport my child away from YMCA Camp Mason/LMTI Summer Leadership Conference for any reason that is deemed necessary by LMTI staff. I understand that in the event that my child must return home (including psychological or physical medical needs, rule infringement, or any other occurrence deemed necessary by LMTI staff), I am responsible for providing transportation.
E. Photo/Video Release
I give permission for photographs/video footage to be taken of the participant (either in person or online), and for photographs/video footage in which the participant is included to be used for purposes of publicity by LMTI and NCADD-Hudson/Partners in Prevention. This includes publication of pictures/video on LMTI websites social media outlets.
F. Chaperone Consent
In the event that my child’s advisor leaves camp during the week, I understand that a trained LMTI adult volunteer or staff member will serve as their action group leader for the duration of the advisor's absence of the conference.
G. COVID-19
I understand that LMTI and YMCA Camp Mason are operating in accordance with Covid-19 federal, state, and local youth camp safety guidelines. I understand the dangerous and infectious nature of the COVID-19 virus, and acknowledge that the COVID-19 virus may be transmitted from person to person even if all federal, state, local, and other COVID-19 guidelines are followed. I understand that LMTI, YMCA Camp Mason, and NCADD-Hudson/Partners in Prevention cannot guarantee that any person will not become infected with the COVID-19 virus. I understand and authorize that the participant may be administered a rapid or other COVID-19 test during camp in the case of COVID-like symptoms or if an exposure occurs. I understand that LMTI staff will only reach out to me (the participants' caregivers) if there is a positive test result for that participant, and I will not be notified otherwise. I also understand that if the participant is tested and the test is positive, the participant will quarantine as per health guidelines, and that I (or my designee) am required to pick the participant up from YMCA Camp Mason by day's end. If the participant is unable to be picked up, I understand and authorize that an LMTI staff member or other designee may provide the participant with transportation from Camp Mason to the participant's home. NOTWITHSTANDING THESE RISKS, I ACKNOWLEDGE THAT THE PARTICIPANT IS VOLUNTARILY PARTICIPATING WITH KNOWLEDGE OF THE DANGERS INVOLVED. I HEREBY AGREE, FOR MYSELF AND THE PARTICIPANT, TO ACCEPT AND ASSUME ALL RISKS OF INJURY, ILLNESS, DISABILITY, DEATH, AND/OR PROPERTY DAMAGE ARISING FROM THE PARTICIPANT ATTENDING THE CONFERENCE, HOWEVER CAUSED. TO THAT END, IN ADDITION TO AND NOT IN LIMITATION OF THE RELEASE, WAIVER, AND INDEMNIFICATION SET OUT IN PARAGRAPH H, BELOW, I WILL NOT HOLD LMTI, YMCA CAMP MASON, NCADD-HUDSON/PARTNERS IN PREVENTION, OR ANY OF THEIR STAFF, PRINCIPALS, OR AGENTS, RESPONSIBLE FOR, AND HEREBY RELEASE EACH AND EVERYONE ONE OF THEM, FROM ANY CLAIMS, DAMAGES, LOSSES, INJURY, OR DEATH, ASSOCIATED WITH COVID-19 AND RELATED MATTERS.
If I have any questions regarding health/safety, I can contact Rachel Taylor, LMTI Director at rtaylor@pipnj.org.
H. Release, Waiver, and Indemnification
I, the undersigned parent/guardian, do hereby execute this release, waiver, and indemnification and agree to represent as follows: The release of YMCA Camp Ralph S. Mason, NCADD-Hudson/Partners in Prevention, the Lindsey Meyer Teen Institute and their employees, and agents from any and all liability, loss, damage, costs, claims or causes of action including, but not limited to, all bodily injuries and property damages arising out of the sole negligence or other acts or omissions of YMCA Camp Mason, NCADD-Hudson/Partners in Prevention, and the Lindsey Meyer Teen Institute I further agree to indemnify and hold harmless the said above from any and all liability, loss, damage costs, or causes of action, including attorney’s fees and witness costs, arising out of the undersigned participation in the Lindsey Meyer Teen Institute (LMTI) Summer Leadership Conference and other events scheduled for the 2025-2026 school year.