Brighter Days Camp - Registration Form

I understand that, in the event medical treatment is required, reasonable effort will be made to contact me.  However, if I cannot be reached, I give my permission to the staff of Carolina Caring, Inc. (“Carolina Caring”) or other venues to seek medical treatment and/or initiate emergency medical services for my child.

I hereby release, defend, indemnify and hold harmless Carolina Caring and other venues from and against any and all claims, damages or liability arising directly or indirectly from or related to my child’s participation in, or observation of, activities during Brighter Days Camp, including but not limited to risk of exposure to and transmission of COVID-19 and other infectious diseases.

I have read this document and had the opportunity to have my questions answered before signing below. I fully understand the contents, meaning and impact of this authorization and release and agree that is binding on me, my heirs, executors, administrators and assigns.

This Medical Release / Liability Wwaiver must be signed before the camper can prticipate in the Brighter Days Camp.

I, the above-named individual, hereby voluntarily agree to be photographed and/or videotaped and authorize the unrestricted use of my image, voice and/or likeness (“My Image”) by Carolina Caring, Inc. and unlimited affiliates (“Carolina Caring”). I claim no right to compensation for any of same. Carolina Caring will not receive any remuneration for the use or reproduction of My Image.

I understand My Image may be used in various publications and media outlets, including but not limited to Carolina Caring’s internet site and social media, and that My Image may include my Protected Health Information (“PHI”), such as diagnosis or name, and that since it will be in the public domain, it will not be protected by federal privacy standards. I waive the right to inspect or approve the use of My Image for any such purpose and agree Carolina Caring shall have full exclusive ownership of any photographs and/or videos taken pursuant to this authorization.

I hereby release, defend, indemnify and hold harmless the Carolina Caring from and against any claims, damages or liability arising from or related to the use of the above-described material, including but not limited to claims of defamation, invasion of privacy, or rights of publicity or copyright infringement, as well as claims related to reproduction, publication and distribution.

I understand that I am under no obligation to sign this form and that Carolina Caring will not condition treatment, payment, or eligibility for health care benefits on my decision to sign this authorization. I also understand I have the right to revoke this authorization at any time and that Carolina Caring must be notified of my desired revocation in writing to: Clinical Privacy Officer, 3975 Robinson Rd, Newton, NC 28658. I may request a copy of this authorization and ask questions about the use or disclosure of my PHI by calling the Clinical Privacy Officer at 828-466-0466.

I understand while Carolina Caring will not permit the further release of my PHI beyond the foregoing date, it cannot call back any prior use or disclosure of same.

I am 18 years of age or older. I have read this document before signing below, and I fully understand the contents, meaning and impact of this authorization and release and that is binding on me, my heirs, executors, administrators and assigns.