Student Camp Visit Form

STUDENT CAMP VISIT FORM

Student Information

Student Name:

Date of Birth:    Student ID:

Parent / Guardian Information

Relationship:    Phone:

Emergency Contact(s)

Relationship:    Phone:

Medical Information & Authorization

Physician Phone:    Health Insurance Provider:

Is the student up to date on required immunizations? Yes No

Camp Visit Details

Camp Name:

Location:

Date(s) of Visit: From to

Departure Time:    Return Time:

Transportation & Activities Consent

I authorize my child to be transported by: School bus School/staff vehicle Other (specify below)

Activities my child may participate in (check all that apply):
Hiking Swimming Low ropes / climbing Educational workshops Other (specify below)

Acknowledgments, Release, and Medical Authorization

By signing below, I certify that I am the parent or legal guardian of the student named above and authorize the student to participate in the described camp visit. I acknowledge that the sponsoring school or organization will make reasonable efforts to supervise participants but that participation involves inherent risks. I release and hold harmless the school, its employees, volunteers, contractors, and agents from liability for injury, loss, or damage to person or property arising from the student's participation, except for acts of gross negligence or willful misconduct.

In the event of illness or injury, if reasonable attempts to contact me have been unsuccessful, I authorize the designated staff to obtain and provide emergency medical care for my child, including transportation to a medical facility, and to consent to examination, treatment, and procedures that are deemed necessary by a licensed physician, surgeon, dentist, or emergency medical personnel. I understand that I am financially responsible for any medical services provided.

I further authorize camp staff to administer the medications listed above according to the directions provided. I will notify the school in writing of any changes to this information prior to the event.

Photo / Media Release: I grant permission for photographs, video, or audio recordings of my child to be used for educational, promotional, or archival purposes by the school or sponsoring organization, provided no personally identifying information is published without separate consent. I do not grant permission

Authorized Pick-up

The following individuals are authorized to pick up the student after the visit. Photo identification may be required.

Relationship:    Phone:

Relationship:    Phone:

Certification

I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that falsification or omission of material information may result in revocation of permission to participate.

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