Individual Release and Understanding

Individual Release and Understanding 2024

You must be 18 years of age or older to fill out this form. One form per attendee. A parent/guardian must complete and sign this form for their camper under 18 and include their contact phone and email as the emergency contact information.
Is the Camper under 18 years old?*

YesNo
Camper's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Contact Phone Number*

Area CodePhone Number
Contact Email Address*
example@example.com
Group Name*
Group you are coming with
Please enter an Emergency Contact who will NOT be at Camp during this retreat.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Family Insurance Company*
Policy Number*

Consent to Release & Understanding

Indicate your consent to each item below.
Activities Release
I, First Name* Last Name*, hereby acknowledge my willful decision to attend Camp Elim and to participate in all activities. I will not hold Camp Elim or its agents liable for injury caused by common accident, illness (including COVID-19 and any of it's variants) or the rendering of emergency care. I give permission to participate in any off-site activities during camp and to be transported to and from these activities, including emergency situations (if any) by authorized vehicles.
Initial here*
Activities Release
I, First Name* Last Name*, hereby give permission for my child {campersName} to attend Camp Elim and to participate in all activities. I will not hold Camp Elim or its agents liable for injury caused by common accident, illness (including COVID-19 and any of it's variants) or the rendering of emergency care. I give permission for {campersName} to participate in any off-site activities during camp and to be transported to and from these activities, including emergency situations (if any) by authorized vehicles.
Initial here*
Medical Release
I, First Name* Last Name*, understand that in the event of an emergency, every effort will be made to contact a responsible relative. In the event that contact cannot be made, I hereby give permission to the camp administration and the physician they may select to secure proper treatment for, to hospitalize, and to order such injections, anesthesia or operations as may be urgently necessary for me. In the event of a claim, family insurance (if any) will be billed. Camp Elim’s insurance provides secondary coverage for injuries sustained at Camp.
Initial here*
Medical Release
I, First Name* Last Name*, understand that in the event of an emergency, every effort will be made to contact a responsible parent or guardian of {campersName}. In the event that contact cannot be made, I hereby give permission to the camp administration and the physician they may select to secure proper treatment for, to hospitalize, and to order such injections, anesthesia or operations as may be urgently necessary for {campersName}. In the event of a claim, family insurance (if any) will be billed. Camp Elim's insurance provides secondary coverage for injuries sustained at Camp.
Initial here*
I give permission to Camp Elim to use video or photography of me or my family members for promotional purposes*

YesNo
By entering your name below and submitting this form you agree to the terms of this release.
Signature*

Clear
By signing I agree to the statements in this form
Typed Signature*
Type your full legal name
Date

MonthDayYear
Date
I'm not a robot*
Should be Empty:

Individual Release and Understanding 2024

Consent to Release & Understanding