If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.
I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.
If the person named herin is a minor, it is my intention that representatives of the camp be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to to provide information to the camp representatives to keep me informed of my child's health situation.
In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, inclulding hospitalization, for the named person. This completed form may be photocopied for trips out of camp.
Camper Agreement
I understand and agree to abide by any restrictions placed on my activity at camp.
I understand that all applications are subject to acceptance by Youth Incorporated. I understand that Youth Incorporated will not allow children that are a danger to themselves, or others, or who are disruptive to normal activities, making it unreasonably difficult for other children to enjoy camp programs or staff to carry out their duties. Disruptive behavior shall be grounds for dismissal and no refunds will be given in such case.
I am aware of the dangers that are inherent in the operation of children's camps, including the dangers or risk associated with specifically, but not limited to equine activities (horseback riding), swimming, boating, canoeing, water skiing, fishing, athletics, ropes courses, hiking, overnight outdoor camping, climbing, crafts, campfires and vehicle travel. In consideration of acceptance of this application, I understand that Youth Incorporated assumes no responsibility for injuries or illnesses, which the applicant may sustain as a result of his/her physical condition resulting from the participation of any camp activities. I expressly acknowledge that I assume the risk and I hereby voluntarily release Youth Incorporated, its agents and employees for any and all injuries and illness, which may result from medical treatment. Prudent and immediate attempts will be made to contact the applicant's parents or guardian. I give my consent for the applicant to leave the campsite in authorized vehicles in case of an emergency. I understand that related medical expenses will be my responsibility.
I authorize Youth Incorporated to make, have and use photographs, slides and/or audio/video tapes of the applicant as may be needed for promotional purposes.
I acknowledge that Youth Incorporated is not responsible for lost, stolen or damaged personal articles. I certify that all Health Forms submitted are correct and complete and that the applicant has my permission to engage in all activities unless exceptions are noted.
