Camper Registration Form 2026

Consent Form
The following consent agreement must be signed by a parent or legal guardian of the minor child in order for the child to attend PruittCares Foundation, Inc. d/b/a Camp Cocoon ("Camp Cocoon" or "Camp").

Your signature below indicates that you acknowledge and agree to each of the following:

1. I hereby attest that this health history and all other information contained in this registration packet is correct to the best of my knowledge, and that my child has permission to engage in all Camp activities except as noted. The staff of Camp Cocoon exercises caution in the conduct of all camp activities; however, neither they, nor Camp Cocoon, assumes responsibility for accidents, injury or illnesses suffered by its campers.

I further understand that serious accidents occasionally occur during Camp activites, and that participants in Camp activities occasionally sustain mortal or serious personal injuries and/or property damage as a consequence thereof. Knowing the risks of Camp activities, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who (through negligence, carelessness, or otherwise) might be liable to my child or to me (or to my heirs or assigns) for damages, along with each of their respective affiliates and employees. For the sake of clarify, any transportation arranged by Camp Cocoon shall be considered a "Camp activity" for all purposes hereunder.

2. Camp Cocoon accepts no responsibility for the loss, damage or theft of property, or for personal injury.

3. Details of my health and accident insurance coverage, if applicable, are as follows:
Insurance Company*
Insurance Policy Number or Medicaid Number*
Insurance Phone Number*
Please enter a valid phone number.
Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. I recognize and understand that Camp Cocoon is operated by PruittCares Foundation, Inc., a charitable organization. My child and I are receiving all of the benefits of Camp Cocoon with minimal or no costs to us and recognize that Camp Cocoon is immune from suit under Georgia's Charitable Immunity Doctrine.

5. In case of medical and/or surgical emergency, I authorize Camp Cocoon's medical staff to render to my child or to arrange for my child to receive any X-rays, anesthetic, medical, dental, surgical diagnosis, treatment, and hospital care which is deemed advisable by and is to be rendered under, the supervision of any physician, dentist or surgeon licensed to practice in the State of Georgia. I also grant permission for a licensed nurse to administer over-the-counter medication such as ibuprofen, acetaminophin, and antihistamine, as needed.

6. I acknowledge that reporters, photographers, videographers and other members of the media may attend Camp Cocoon in order to increase the awareness about Camp Cocoon and its programs. I grant permission for my child to be interviewed, photographed, and filmed by any member of the media at Camp Cocoon. I understand that Camp Cocoon is not responsible for the content of the media coverage and that my child will not be paid for any media work.

7. Camp Cocoon and its representatives have absolute permission to use my child's image in a photograph or video or my child's artwork that pertains to the lawful programs and activities of the Camp.
I agree that the above paragraphs pertain to the following child, of whom I am the parent or legal guardian. (Please enter the child's name below.)*

First NameLast Name
By clicking the box below, I consent to sign this consent form electronically. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature.*

I agree
I agree to all terms and conditions in this consent form.*
Electronic Signature
Date of Signature*

MonthDayYear
Date
Signer's Relationship to Camper*

ParentGuardianCaseworker
Should be Empty:

Camper's Information

Deceased Loved One's Information

Parent/Guardian with Whom Child Lives

Alternate Emergency Contact

Allergies

Medical Emergencies

General Health Questions

Medications

Other Needs

Emotional/Behavior Questions