As a parent/guardian, I hereby give permission for the designated child to attend the Episcopal Youth Camp in the Diocese of Western Michigan and to participate in all the activities except as noted above and give permission for my child to be transported in cases of emergency or for a planned program. I understand that my child must follow the rules set forth by the Diocese of Western Michigan. If dismissal because of a disciplinary problem occurs, transportation will be provided by or paid by the person or a parent and any registration fees will not be reimbursed. A copy of the incident report and the course of action will be kept in the camp files, be sent to the person’s home rector or sponsoring clergy person and be sent to the Bishop.
This health history is correct and complete as far as I know. I give permission to the camp to provide routine health care, administer medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician/nurse selected by the camp to secure and administer treatment, including hospitalization, for the person named above. Information in this completed form may be printed and photocopied as necessary.
I agree to hold the Diocese of Western Michigan and any associated agencies and persons harmless and waive any claims for payment of accident, injury, disability or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activity.