Camper Medical Form
Name: _____________________________ Birthday: ____________ Age: ________
Parent or Guardian: ____________________________________________________
Home Address:________________________________________________________
In case of emergency, contact: ___________________________________________
Phone: _______________________ Address:______________________________
____________________________________________________________________
If the camper is on any medication, what is the medicine and dosage?____________
Approximately, when was the camper’s last tetnus shot? ______________________
____________________________________________________________________
Does the camper have any allergic reactions? If so, please list allergies__________
____________________________________________________________________
Any serious injuries or conditions? ________________________________________
Are there any conditions that we need to be aware of? (such as; asthma, bed wetting,
sleep walking, diabetes, HIV,etc.) These conditions will be kept confidential by camp staff
____________________________________________________________________
____________________________________________________________________
Name of Physician: ____________________________ Phone: __________________
Insurance Company: _________________________ Policy No.: _________________
Important: Please notify the camp if this child has been exposed to a communicable disease during the three weeks prior to camp. All medications will be kept and dispensed by the camp nurse. In case a certified nurse is not on staff, medications will be dispensed (according to the directions on the label) by the Ass't director. A physical examination is recommended before camp begins. In case of emergency, I understand every effort will be made to contact parents or guardians of the camper. In event I cannot be reached, I hereby give my permission (to the physician selected by the camp director) to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child, as named above.
____________________________________________ _______________
parent or guardian signature date
Authorization of Release
I hereby grant Icthus Camping
Ministry, Inc. (Camp Icthus)
the following rights:
The right to use my child’s photograph, picture, likeness, and voice (hereinafter collectively known as image) in connection with its camp materials and promotion. The right to use, reproduce, publish, exhibit, distribute, and transmit my child’s image individually or in conjunction with other images or printed matter in the production of brochures, motion pictures, television tape, sound recordings, still photography, CD-ROM, and other media. The right to copyright, in its own name, works that contain my child’s image hereby waive the right to inspect or approve my child’s image or any finished materials that
incorporate my child’s image. I understand and agree that I will receive no compensation, now or in the future, in connection with the use of my image hereby release and forever discharge Icthus Camping Ministry, Inc. (Camp Icthus),their officers, agents, and employees from any and all claims, demand, rights, and causes of action of whatever kind that may arise from the use of my image, including all claims for libel and invasion of privacy. I understand that the acceptance of this release form by Icthus Camping Ministry, Inc. (Camp Icthus) shall not constitute a waiver, in whole or
in part, of sovereign immunity by said organization, officers, agents, and employees.
RELEASE, WAIVER, AND INDEMNITY AGREEMENT
IT IS THE INTENTION OF
______________________________________ (parent or guardian) BY THIS AGREEMENT TO
EXEMPT AND RELIEVE CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN FELLOWSHIP
CAMP ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR
PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF (NAME OF MINOR) CAUSED
BY ANY ACT OF NEGLIGENCE OF CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN
FELLOWSHIP CAMP AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting___________________________(NAME OF MINOR)AND FURTHER IDENTIFIED AS “CAMPER”
to observe, or use any facility or equipment of CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN FELLOWSHIP CAMP, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: MOUNTAIN FELLOWSHIP CAMP in the city of SUCHES, , County of UNION, and State of GEORGIA, the undersigned parent and/or guardian of “CAMPER”: hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to (NAME OF MINOR) as a result of (NAME OF MINOR)'s observing or using facilities or equipment of CAMP ICTHUS, ICTHUS CAMPING MINISTRY/MOUNTAIN FELLOWSHIP CAMP, or engaging in or receiving instructions in any
activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian of “CAMPER” for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN FELLOWSHIP CAMP or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless CAMP ICTHUS, ICTHUS CAMPING MINISTRY/MOUNTAIN FELLOWSHIP CAMP and its officers, agents, servants, or employees
from any and all claims or causes of action by “CAMPER” or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of “CAMPER” present any claim against CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN FELLOWSHIP CAMP and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by CAMP ICTHUS, ICTHUS CAMPING MINISTRY/ MOUNTAIN FELLOWSHIP CAMP and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and
unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
DATED:
SIGNATURE OF PARENT OR GUARDIAN FOR “CAMPER”: