Camper Information

Guardian Information

Emergency Contact Information

In exchange for Camper’s participation in the BRG Burn Survivor Camp, Camper/Guardian agrees as follows:

Acknowledgement of Risk. In consideration of the risk of injury while participating in BRG Burn Survivor Camp (the “Activity”), and as consideration of the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or person representatives, knowingly and voluntarily enter into this Waiver and Release of Liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in this Activity, and do hereby release and forever discharge Baton Rouge General Medical Center, Baton Rouge General Foundation and BRG Burn Survivor Camp, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activity, including traveling to and from the BRG Burn Survivor Camp and/or any event related to this Activity.

I further acknowledge and fully understand that there are inherent risks of serious injury or death associated with playing sports, hiking, biking, swimming, canoeing, paddle boating, basketball, volleyball, fishing, slip and slide, tug-of-war, horseback riding, skating, bowling, baseball and all other activities associated with the camp experience. These inherent risks also include, but are not limited to: acts or omissions of other Campers, the condition of equipment or property, even if properly maintained; weather conditions (such as lightning strikes, sunburns, rain or hail storms, tornadoes and the like), contact with plants, animals or insects, the risk of Camper engaging in unauthorized activities, Camper’s physical conditions or Camper’s own acts and omissions. I further acknowledge that all inherent risks associated with activities at Summer Camp cannot be fully described as part of this document.

I acknowledge and agree no illegal drugs or substances, any form of marijuana or psilocybin mushrooms, firearms, knives, pepper spray and other aerosols, vape pens, smoking paraphilia, tobacco, chemicals, explosives, and other items as determined by BRG Burn Camp Representative, are permitted to be brought with Participant. I further acknowledge and agree that as a Participant, the Participant is subject to a bag check.

I understand that any items Participant brings to BRG Burn Survivor Camp (personal effects, camera, cell phone, other personal electronics, jewelry, etc.) are the sole responsibility of Participant, and Baton Rouge General Medical Center, Baton Rouge General Foundation BRG Burn Survivor Camp is no way responsible for lost, missing, stolen or damaged items.

I acknowledge and agree that in the event that Camper/Participant should be prohibited for any reason from completing the BRG Burn Survivor Camp at any time during the duration of the Camp, the Parent/Guardian will be responsible for personally picking up at the location of the BRG Burn Survivor Camp.

I agree to indemnify and hold Baton Rouge General Medical Center, Baton Rouge General Foundation and BRG Burn Survivor Camp against all claims or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related cost, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf.

Optional Permission. The following items are not necessary requirements for Camper’s participation in activities:

Medical and/or Hospital Treatment Release:

I HAVE READ AND UNDERSTOOD THE ABOVE WAIVER AND RELEASE. I AGREE IT IS MY INTENTION TO VOLUNTARILY INDEMNIFY AND HOLD HARMLESS BATON ROUGE GENERAL MEDICAL CENTER, BATON ROUGE GENERAL FOUNDATION AND BRG BURN SURVIVOR CAMP FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER ACTION OR INACTION.

I voluntarily, for myself or in my legal capacity as parent/guardian of Minor, accept and assume full responsibility for these risks as well as any and all other risks associated with the use of Camp’s Facilities and participation in Camp’s Activities and Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

I, the above listed Participant, desire to come voluntarily to Camp Escape, Inc. d/b/a Camp Tanglewood and Tanglewood Plantation LLC d/b/a Tanglewood Retreat (collectively, “Tanglewood”) located at 1403 Tanglewood Road, Lawrence, MS 39336, and to engage in the activities related to being a Participant. I hereby freely, voluntarily, and without duress execute this Waiver and Release of Liability under the following terms:

I, the Participant, release and forever discharge and hold harmless Tanglewood, their directors, officers, employees, affiliates and agents, and their successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from the Participant’s Activities with Tanglewood.

I understand that this Waiver discharges Tanglewood from any liability or claim that I, the Participant, may have against Tanglewood with respect to bodily injury, personal injury, illness, death, or property damage that may result from or during my activities on Tanglewood’s event site. I also fully understand that Tanglewood does not assume any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage.

I, the Participant, understand that I expressly waive any such claim for compensation or liability on the part of Tanglewood in the event of such injury or medical expense. I hereby release Tanglewood from any claim whatsoever which arises or may arise in the future on account of any first aid, medical treatment, or other service rendered in connection with my activities with Tanglewood.

I understand that my activities with Tanglewood may include various activities that may be hazardous to me, and I hereby expressly and specifically assume the risk of injury or harm in these activities and release Tanglewood from all liability for injury, illness, death, or property damage resulting during my activities with Tanglewood.

I acknowledge and understand the following:

• Participation includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist;
• I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties; and
• I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind on the part of the Released Parties.

I grant unto Tanglewood all right, title, and interest in any and all photographic images and video or audio recordings that are made by Tanglewood during my activities with Tanglewood, including, but not limited to, any royalties, proceeds, or other benefits that are derived from such photographs or recordings.

I expressly agree that this Waiver and Release of Liability is intended to be as broad and inclusive as permitted by the laws of the State of Mississippi and that this Waiver and Release of Liability shall be governed by and interpreted in accordance with the laws of the State of Mississippi. I agree that in the event that any clause or provision of this Waiver and Release of Liability shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to enforceable.

Photographs and film have been taken by or on behalf of “Shell”. You or your child may be recognizable in these photographs or film. We request your consent to use and process these materials.

In respect of photographs and film in which I am / my child is recognizable I hereby provide my consent for Shell and companies within the Shell group of companies: to use and process these materials for general publicity and commercial purposes of Shell, including paid advertising through the means specified below:

• Print media including: newspapers, magazines, booklets, posters, brochures and flyers
• Online media including: YouTube, LinkedIn, Facebook, Twitter and Instagram
• Shell’s own media including: Shell’s website, Shell’s internal sites
• Events including: conferences, trade shows, exhibitions and festivals
• Television media including: traditional, satellite and online

I understand that:

• Shell owns all copyright in and / or has the right to use the materials.
• All materials will be processed and protected in line with the Events Supplementary Privacy Notice.
• I may withdraw consent, subject to local law that provides otherwise, at any time.
• Withdrawal of consent does not affect the lawfulness of the processing and use of the materials up to that moment and we may retain and process material in our corporate archive for separate public interest or historical or statistical research purposes or where required by applicale law or regulation.
• I may contact the Shell Group Chief Privacy Officer at Privacy-Office-SI@shell.com, in case I have any issues, queries or complaints regarding the processing of the materials. I may also contact the Shell Group Chief Privacy Officer at Shell International B.V. The Hague, The Netherlands - Trade Register, No. 27155369 Correspondence: PO Box 162, 2501 AN, The Hague.