I certify that the Health History I have provided is true and correct so far as I know, and I believe that my child’s health is satisfactory to participate in a program that involves physical activities. I understand that there are risks associated with this program, which may give rise to medical emergencies requiring immediate health care. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by She Won Empowerment Camp to: hospitalize, secure proper treatment for, and order injections, anesthesia, or surgery for my child.
I also agree to assume full financial responsibility for paying all costs and expenses associated with the provision of medical care pursuant to this authorization including any cost associated with any specialized means of evacuation necessary to transport my child to an appropriate medical care facility.
I further affirm that I have fully disclosed to the She Won Empowerment Camp and their agents any and all health conditions which may bear on my child’s ability to safely complete the activities in good health or which put my child at increased risk or injury.
I grant permission for my child to participate in all activities offered at camp except as otherwise noted on this form. I hereby release, indemnify, and hold harmless Antioch Church of Long Beach, She Won, and Hiding Behind the Lipstick, its agents, owners, officers, and employees from and against any and all claims, liabilities, suits, actions, damages, or losses, including without limitation, all costs and attorney's fees and including without limitation any act, omission, negligence or gross negligence of the She Won Empowerment Camp, it agents, owners, officers, and employees which may arise from or in any way be connected with my stay or participation in activities at the She Won Empowerment Camp. I agree that any dispute concerning, relation, or referring to this contract, concerning my child’s camping experience, or the camping experience itself shall be resolved exclusively by binding arbitration with venue in Los Angeles County.