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Summer Camp Authorization Form

The document is a consent form for a summer camp. It provides information about activities at the camp and obtains permission for the camper's participation in various programs, transportation, medication administration, and emergency medical treatment. The parent or guardian must sign the form in the presence of a notary public to enroll the camper.

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9 views

Summer Camp Authorization Form

The document is a consent form for a summer camp. It provides information about activities at the camp and obtains permission for the camper's participation in various programs, transportation, medication administration, and emergency medical treatment. The parent or guardian must sign the form in the presence of a notary public to enroll the camper.

Uploaded by

itr4731m
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Presbyterian Camp and Conference Ministries of SW Florida, Inc.

SUMMER CAMP AUTHORIZATION AND CONSENT FORM


Please complete all sections of this form. Remember to sign only in the presence of a notary public.

Camper Name: ___________________________________________________________________________

Waiver of Liability and Authorization to Participate


I accept full responsibility for myself or my child in the case of bodily injury, death, loss of personal property, and expenses thereof and I hereby
waive any claims or demands which I or any member of my family may have against Presbyterian Camp and Conference Ministries of SW Florida,
Inc., its employees, volunteers, officers, or directors, that may result from negligence by Presbyterian Camp and Conference Ministries of SW
Florida, Inc., its employees, volunteers, officers, or directors. If there is any question regarding my child’s ability to participate in these activities, I
will inform camp staff prior to allowing my child to participate. I understand that my child is required to follow established rules and procedures
associated with each activity. I acknowledge the nature of the activities and the fact that not all the stresses and hazards connected with the
activities can be foreseen. I recognize that there is a significant element of risk in any adventure, sport, or activity associated with the outdoors.
Knowing that there are inherent risks, dangers, and rigors involved in the activities, I permit my child to participate in the activities of this camp.

I give permission for my child to be transported for approved off-site activities or emergencies in camp-owned vehicles driven by licensed and
insured drivers who are age 21 or older and who have been cleared to transport campers by our insurance carrier.

Authorization to Provide Emergency Care


I understand that every reasonable effort will be made to contact me at the contact information I have provided in the event of an emergency.
If I cannot be reached at the contact information supplied, I hereby give permission to the physician selected by Presbyterian Camp and Confer-
ence Ministries of SW Florida, Inc., to hospitalize, secure treatment for, and to order injection, anesthesia, or surgery for my child as named herein.
I give permission for the release of the Health and Information Form as well as any accompanying information or medical records to medical
professionals in the event of injury or illness. I hereby certify that the information I have provided in the registration materials and Health and
Information Form is complete and accurate.

Authorization for Administration of Medication


I give permission for non-prescription medication to be given to my child by the camp’s health care manager, if deemed necessary. I give
permission for any prescription medications brought to camp by my child to be administered by the camp’s health care manager, who will ad-
minister the medication according to the directions on the pharmaceutical container, unless otherwise directed by a physician. Additionally, I
understand that all medications (prescription and non-prescription) brought by my child to camp will be turned over to and stored by the camp
health care manager.

Legal Restrictions
_____YES _____NO Is anyone legally restricted from seeing your child? (If yes, name:________________________________________)
_____YES _____NO Do you prohibit the use of photography and video recordings of your child in camp publicity?
(By checking “yes”, your child will not be included in the group picture we send home at the end of the week.)

Tampa Bay Presbytery and Peace River Presbytery Discount


Program prices listed in the brochure and on the website reflect the full tiered price for each camp. Members of churches in either Peace River or
Tampa Bay Presbyteries receive a $20 discount for each camp. To receive the discount, you MUST have the following signed by a Minister, Youth
Director, or Director of Christian Education.

Name of Minister, Youth Director, or DCE (please print): ________________________________________ Date: _______________

Signature of Minister, Youth Director, or DCE: ________________________________________

__________ As legal guardian, I agree to the terms above for the camper named herein.
initial here

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Presbyterian Camp and Conference Ministries of SW Florida, Inc.
SUMMER CAMP AUTHORIZATION AND CONSENT FORM
Camper Name: ___________________________________________________________________________
Please initial the following activity consent sections.
Elevated Challenge Course Consent [campers 12 and older may participate]
The elevated challenge course consists of 13 challenge elements suspended 24 feet high, designed, built, and annually certified by an accred-
ited organization specializing in elevated challenge courses. I understand that course procedures and equipment are designed to keep partici-
pants safe on the ground and on the course and that the activity will be facilitated by staff certified to do so.

_____ YES, I give my child permission to participate on the elevated challenge course; he/she will be 12 years of age.
_____ NO, I do not give permission for my child to participate on the elevated challenge course.

Climbing Wall Consent [all campers may participate]


The climbing wall is 25 feet tall and has four climbing lanes, each equipped with hydraulic auto-belay systems for safety and controlled descent.
I understand that climbing wall procedures and equipment are designed to keep participants safe and that the activity will be facilitated by
trained staff.

_____ YES, I give permission for my child to participate on the climbing wall.
_____ NO, I do not give permission for my child to participate on the climbing wall.

Zip Lines Consent [all campers may participate]


Cedarkirk has two zip line courses, the largest having a launch platform 19 feet high and travel distance of 200 feet. I understand that zip line
procedures and equipment are designed to keep participants safe and that the activity will be facilitated by trained staff.

_____ YES, I give permission for my child to participate on the zip lines.
_____ NO, I do not give permission for my child to participate on the zip lines.

Parent/Guardian Authorization for Medical Treatment


I hereby authorize that the information contained in the accompanying Camper Health & Information Form is correct and give Cedarkirk/PCCM
permission to provide my child ongoing health care and to release the information on my child’s Camper Health & Information Form to medical
professionals in the case of illness or accident.

In the case of an emergency, I understand that every effort will be made to contact me or my designated emergency contact(s). In the event we
cannot be reached, I hereby give permission to the physician selected by Cedarkirk staff to secure treatment for, hospitalize, and to order x-rays,
routine tests, injection, anesthesia, or surgery for the camper named in this document. This form may be photocopied for use during off-site
camp programs; all non-original copies will be destroyed at the conclusion of my child’s camp session.

Signature of Parent/Guardian (sign only in presence of Notary Public)


By signing below, I agree to all statements in this Authorization and Consent Form:

Name (please print): _________________________________ Signature: _________________________________ Date: ____________

The foregoing instrument was acknowledged this __________ day of __________ by ______________________________ (name of signer), who
personally appeared before me and acknowledged that he/she signed the instrument voluntarily for the purposes expressed in it.

Signature of Notary: ______________________________

Date: ____________________

State of ____________________

County of ____________________

Personally known OR identification provided: ______________________________ Notary Stamp/Seal

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