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Memorialparkchurch.org


Summer Surge Health and Release Form 2012
Family Last Name__________________________
In case of emergency, contact:
Circle Session: June 25 - 29 July 9 - 13 July 16 - 20

Name:____________________________________________ Relationship to Camper:___________________________
Number contact can be reached during camp: ( )____________________ OR ( )________________________
Name:____________________________________________ Relationship to Camper:___________________________
Number contact can be reached during camp: ( )_____________________ OR ( )_______________________
Is contact at camp?________Name?____________________________ Camp location? ________________________
Complete for all campers even if no conditions exist. Mark all current conditions with an “X” and explain below.
The more familiar the counselors are with your child, the more positive the experience will be for them!
Camper Name:_________________________________ JR / DAY Age:____ Weight_______ *in case of medical treatment
______ Dizziness/Fainting ______ Frequent Headaches/Stomachaches ______ Easy Bruising/Bleeding ______ Heart Problem ______ Learning Support needed:_____________________________________________________________ Shots up to date?______________
Explain special instructions or concerns:_________________________________________________________________
List any allergies and describe symptoms or reaction and the severity:
Food____________________________________ Insect/Environmental______________________________________
Allergic to any medications?________________________ Will you provide Camp Nurse with an Epi-pen?___________
Emergency treatment:______________________________________________________________________________
Camper Name:_________________________________ JR / DAY Age:____ Weight_______ *in case of medical treatment
______ Dizziness/Fainting ______ Frequent Headaches/Stomachaches ______ Easy Bruising/Bleeding ______ Heart Problem ______ Learning Support needed:____________________________________________________________ Shots up to date?______________
Explain special instructions or concerns:_________________________________________________________________
List any allergies and describe symptoms or reaction and the severity:
Food____________________________________ Insect/Environmental______________________________________
Allergic to any medications?________________________ Will you provide Camp Nurse with an Epi-pen?___________
Emergency treatment:______________________________________________________________________________
Camper Name:_________________________________ JR / DAY Age:____ Weight_______ *in case of medical treatment
______ Dizziness/Fainting ______ Frequent Headaches/Stomachaches ______ Easy Bruising/Bleeding ______ Heart Problem ______ Learning Support needed:_____________________________________________________________ Shots up to date?___________
Explain special instructions or concerns:_________________________________________________________________
List any allergies and describe symptoms or reaction and the severity:
Food____________________________________ Insect/Environmental______________________________________
Allergic to any medications?________________________ Will you provide Camp Nurse with an Epi-pen?___________
Emergency treatment:______________________________________________________________________________
Please read all of the following carefully and sign all places where indicated
Permission for treatment
In the event of a minor illness or injury, I understand that my child(ren) will receive BASIC FIRST AID, and that a log of
treatment rendered will be maintained by the Camp Nurse. When deemed appropriate, or upon request, a copy will be
sent home with my child. Such minor care may, at times require the administration of “over the counter” medications. I
hereby give my permission to the Camp Nurse or his/her designee to administer the following medications (dose based on
weight) as they deem appropriate. I have indicated “NO” beside the medications I do not wish my child(ren) to be given
without my prior notification or under any circumstances. Otherwise, I understand that any time a medication is given, I
will be notified after it is administered.
■ Tylenol or Advil for fever/pain ■ Benedryl for allergic reactions ■ Tums or Rolaids for stomach upset ■ Visine Allergy Eye Drops for allergic reactions involving eyes ■ Benedryl Spray for allergic rashes/minor skin bites ■ Topical Antibiotics for abrasions, minor cuts ■ Topical Xylocaine Sprays (Solarcaine) for sunburn/other minor burns
If my child requires scheduled medication on a daily basis, I understand that it is my responsibility to provide such
medication in a container labeled with my child’s name, the name of the medication, the schedule of administration and
the prescribing physician’s name. If my child requires an inhaler, an epi-pen, sunscreen or any other special medications,
I understand that it is my responsibility to deliver and pick up such items from the Camp Nurse and to provide the
necessary instructions in writing.
In the event of a medical emergency, I understand that every effort will be made to contact a parent or guardian of the
camper. In the event that I cannot be reached, I hereby give my permission to the Camp Director and/or the Camp Nurse
to seek medical attention for my child. I also give permission to the hospital and/or physician secured by the camp to
hospitalize, to provide appropriate treatment for, and to order injection, anesthesia, and/or surgery for my child as his/her
illness or injury warrants.
Signature of parent/guardian______________________________________________Date______________________
Hospital preference (emergency only)_________________________________________________________________
Insurance Company ___________________________________________Policy #_____________________________

Consent and Liability Release
Campers will be engaged in team activities that include, without limitation, interactive games involving running, jumping,
climbing and other physical activity that are sports related including bouncing on the moon walk, playing on playground
equipment and water games. Although Memorial Park Church (MPC) will use reasonable efforts to minimize risks,
participation will expose the Camper to the possibility of accidents, including, but not limited to cuts, sprains, abrasions,
and other minor injuries. The undersigned parent or legal guardian of the Camper hereby voluntarily consents to the
Camper’s participation in all Summer Surge activities, except as otherwise specified in writing. Furthermore, the
undersigned hereby forever releases, acquits, discharges, and agrees to hold harmless MPC and its agents, employees,
directors, officers, successors, assigns, and volunteers, from any and all claims, demands, actions and causes of action of
any sort, for personal injury or damage to property arising out of or sustained during the Camper’s presence on the MPC
property and participation in Summer Surge. The undersigned hereby certifies that he/she has read the foregoing and
has been fully informed of the risks involved in the Camper’s participation in Summer Surge.
Signature of parent/guardian_________________________________________________Date_________________
Photo Release
The undersigned parent or legal guardian of the Camper, gives permission to publish or reproduce photographs of the
Camper captured during Summer Surge by the MPC staff or by local media to use for presentations or promotional
purposes (including brochures, power point slide show, newspaper and website). The undersigned agrees that the
photographs and related products shall be the sole property of MPC and hereby waives any rights of compensation or
ownership with respect thereto. The undersigned waives any applicable publicity, privacy, or other likeness rights related
to the photographs of the Camper and expressly indemnifies, releases, discharges, and holds harmless MPC and it
agents, employees, directors, officers, successors, assigns, and volunteers from any and all claims arising out of such
photos including, without limitation, any violations of the rights of publicity, privacy, or other likeness rights.
Signature of parent/guardian__________________________________________________Date_________________
TO BE COMPLETED AND RETURNED BY ALL DAY CAMPERS
Climbing wall permission and Memorial Park Church release form
Dear Parents of Day Campers, Please go over this release with your child, have him/her initial as indicated, sign as indicated, and return with your camper application and health form. We will begin using the climbing wall on the first day of Summer Surge and we MUST have this signed release before your child(ren) may participate. I acknowledge the inherent extreme risk in both low and high Challenge Course activities associated with the climbing wall at the Memorial Park Church’s Clayton Community Youth Center. I realize that those risks include falls, equipment failure, bad decision-making, inattentive belayers, and holds that have become loose or damaged by other climbers. I understand that there are unforeseeable, freakish accidents, and I assume all risks associated with such accidents, even though I cannot foresee them. I agree to pay attention to the state of the equipment at the rock wall course area, and to advise the staff if I do any damage or notice any damage. I have been informed of and agree to abide by all of the safety rules. I agree to obey any instruction give to me by Memorial Park Summer Surge staff regarding use of the climbing wall. ____________ (initial of climber or climbers) I am physically fit and know of no medical or health reason why I should not participate in the activities that take place with the rock climbing wall at Clayton Community Youth Center. ____________ (initial of climber or climbers) This release applies to and binds the personal representative, heirs, and family of the climber(s). If a member of the family under the age of 18 accompanies the climber stated below to the climbing area, I make this release and these representations on his or her behalf, and I agree to assume responsibility for his or her safety. I understand that this release is a binding legal contract. I sign it of my own free will. I also understand that this contract is severable; In other words, that if any part of it is held by a court of law to be unenforceable, the rest of it shall survive. I acknowledge that no participant in Summer Surge will be permitted to use the climbing wall unless this release is signed by a parent or guardian of that participant. MY CHILD(REN) NAMED BELOW _____HAVE MY PERMISSION TO CLIMB THE WALL AT THE CLAYTON COMMUNITY _____DO NOT HAVE MY PERMISSION TO CLIMB THE WALL AT THE CLAYTON COMMUNITY YOUTH CENTER AT MEMORIAL PARK CHURCH Parent or Legal Guardian’s printed name: ____________________________________________________ Parent/Guardian Signature________________________________________Date:_____________________ Emergency phone # during camp:_____________________ Child’s Name:______________________________________________________ Age: _______________ Child’s Name:______________________________________________________ Age:_______________ Child’s Name:______________________________________________________ Age:_______________

Source: http://memorialparkchurch.org/Websites/memorialparkchurch/images/children/Health_Application_and_Climbing_Wall_Release__12.pdf

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