Fill and Sign the Ojibwe Camp Release and Waiver Bemidji State University Form

Consent Form for Camp Waiver and Release from Liability Page 1 of 2 Consent Form for Camp Waiver and Release from Liability I, , the Parent (or Guardian) acknowledge that my (Your Name) Child’s participation in the 2015 Camp for Kids of (Name of Church) is voluntary and may involve risks and require involvement in activities that require physical exertion. Such activities may include, but are not limited to: athletic games, off-site excursions, group activities and team events. I acknowledge that my Child’s participation in any Camp for Kids activity presents risks such that my Child may suffer property damage, bodily injury, or death. Therefore, in consideration of my Child’s participation in the 2015 Camp for Kids, I agree to the following:  is not responsible for personal belongings. (Name of Church) I consent to having photographs taken of my Child during Camp for Kids. The pictures may be used on the Church’s web page, in future brochures, or in slide shows after the event.  Inappropriate conduct by my Child may result in immediate expulsion from the program. If this occurs I agree to make arrangements for my Child to be immediately picked up from the Church. In consideration for the privilege of allowing my Child to participate in the 2015 Camp for Kids, I hereby release and hold (Name of Church) harmless the Church, its officers and agents, from any liability to or responsibility for bodily injury, damage or illness to the Child while participating in the aforesaid activity. Further, I agree to indemnify and hold harmless the Church, its officers and agents with respect to any claim asserted by or on behalf of my Child as a result of bodily injury, illness, or damage. PLEASE READ THIS DOCUMENT CAREFULLY. IT CONTAINS A RELEASE OF LIAIBLITY AND A PROMISE TO INDEMNIFY. Parent/Guardian’s Telephone number(s) are: Home: Work: . Emergency Information: In an Emergency Contact: Primary Phone #: Secondary Phone #: Other Phone #: Insurance Company: Consent Form for Camp Waiver and Release from Liability Page 2 of 2 Known allergies of Child: Special medical history of Child: I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility to treat my Child for the purpose of attempting to treat or relieve any injury received by my Child. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting to treat to relieve any such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and my Child minor. I further agree to pay all charges for the dental, medical or hospital care of treatment rendered to my Child. Witness our signatures this the of , 20 . (Name of (Child) (Name of Parent or Guardian) By:___________________________________ (Signature of Child) (Signature of Parent or Guardian) (Printed Name Child) (Printed Name of Parent or Guardian)