Camp Participation and Release Form
LightHouse for New Hope - Summer Grief Camp
Guardian/Parent
First Name
Last Name
Email
*
example@example.com
Relation to Child/Children
Camper 1: Name
First Name
Last Name
Camper 2: Name
First Name
Last Name
Camper 3: Name
First Name
Last Name
PARTICIPATION CONSENT: I authorize my child to participate in the Lighthouse for New Hope Grief Camp conducted at the above location. I understand that this camp is a peer-based grief support program for children who have experienced the death of a loved one. Activities may include structured group discussions, emotional expression, creative arts, and age-appropriate recreational activities. I acknowledge that this program is supportive and educational in nature and is not psychotherapy, clinical counseling, or medical treatment.
I Consent
MEDICAL AND EMERGENCY AUTHORIZATION: I confirm that all relevant medical conditions, allergies, medications, and authorized pickup information have been fully disclosed on the Camp Enrollment Form. In the event of illness or injury and I cannot be reached, I authorize Lighthouse for New Hope staff to obtain appropriate emergency medical care for my child. I understand that I am responsible for any medical expenses incurred.
I Consent
FOOD SERVICE ACKNOWLEDGEMENT: I understand that lunch, snacks, and beverages will be provided during camp hours. If your child requires special dietary accommodations, we ask you to provide for their lunches and snacks. I acknowledge that an allergen-free environment cannot be guaranteed.
I Consent
ATTENDANCE AND TIMELY PICKUP: Camp hours are 9:00 AM to 1:00 PM. I understand that my child must be picked up promptly at 1:00 PM by an authorized adult listed on the Enrollment Form. If a child is not picked up and contact cannot be made, Lighthouse may contact emergency contacts provided. Repeated late pickup may result in dismissal from camp to ensure appropriate supervision and staff capacity.
I Consent
ASSUMPTION OF RISK AND RELEASE OF LIABILITY: I understand that participation in campactivities involves ordinary and inherent risks associated with groupactivities, creative materials, and general childhood movement. On behalf of mychild, I voluntarily assume these risks and release Lighthouse for New Hope,its board members, employees, and volunteers from liability for injury,illness, or damages arising from participation, except in cases of grossnegligence or willful misconduct
I Consent
CONFIDENTIALITY AND MANDATED REPORTING: I understand that personal sharing may occur in group settings. While confidentiality is encouraged among participants, Lighthouse for New Hope cannot guarantee that other children will maintain confidentiality. I understand that staff and volunteers are mandated reporters under Texas law and are required to report suspected abuse, neglect, or credible threats of harm to the appropriate authorities.
I Consent
MEDIA RELEASE: (Optional - please select one)
I grant permission for my child’s image orlikeness to be used in Lighthouse for New Hope materials, including website,social media, newsletters, and other communications.
I do not grant permission for my child’s imageor likeness to be used.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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