Medical Release / Waiver Of Liability Form Page 2

 

Camper   N ame:   _ ___________________________________________Birthdate:__________________________  

 

5.

Has   y our   c hild   e ver   h ad:  

 

Seizures_____  

Asthma______     D iabetes_______   Heart   d isease______       O ther_______________________________  

 

 

6.

Date   o f   l ast   t etanus   s hot:_____________  

 

Please   s ign   O NLY   O NE   o f   t he   f ollowing   s tatements   r egarding   i nsurance:  

1.) I   h ereby   g ive   m y   c onsent   t o   a ny   e mergency   m edical   t reatment   n ecessary   f or   m y   c hild   r esulting   f rom   a n  

accident   o r   i llness.   I   a ccept   f inancial   r esponsibility   a nd   u nderstand   t hat   m y   i nsurance   w ill   b e   b illed   b efore  

Brotherhood   M utual,   w hich   i s   t he   c arrier   f or   C amp   B eaverfork.  

 

Parent/Guardian   S ignature____________________________________________  

 

2.) I   h ereby   g ive   m y   c onsent   t o   a ny   e mergency   m edical   t reatment   n ecessary   f or   m y   c hild   r esulting   f rom   a n  

accident   o r   i llness.   I   c ertify   t hat   n either   I   n or   m y   f amily   h as   a ny   t ype   o f   h ealth   i nsurance   c overage.  

 

Parent/Guardian   S ignature_____________________________________________  

 

Date   o f   C amp   W eek   A ttending__________________________________________  

 

CAMP   B EAVERFORK   N O   L ONGER   H AS   P RIMARY   P AY   I NSURANCE.   W E   C ARRY   S ECONDARY,   W HICH  

MAKES   T HE   C OMPLETION   O F   T HIS   F ORM   A N   I MPERITIVE.  

__________________________________________________________________________________________  

Please   r ead   a nd   s ign   t he   b elow   W aiver   o f   L iability   A greement:  

1) We,   ( I)   o n   b ehalf   o f   m y   c hild-­‐participant   d o   h ereby   r elease,   f orever   d ischarge   a nd   a gree   t o   h old   h armless   C amp  

Beaverfork   /   A rkansas   F ree   W ill   B aptist,   I nc.   a nd   t he   d irectors   t hereof   f rom   a ny   a nd   a ll   l iability,   c laims   o r   d emands   f or  

personal   i njury,   s ickness   o r   d eath,   a s   w ell   a s   p roperty   d amage   a nd   e xpenses,   o f   a ny   n ature   w hatsoever   w hich   m ay   b e  

incurred   b y   t he   u ndersigned   a nd   t he   c hild-­‐participant   t hat   o ccur   w hile   s aid   c hild   i s   p articipating   a t   S ummer   c amp.  

 

2) I   g ive   p ermission   f or   a ll   p ictures   a nd   v ideo   t aken   d uring   t he   w eek   o f   c amp   t o   b e   u sed   b y   C amp   B eaverfork   i n   a ny   m edia  

format   i ncluding   b ut   n ot   l imited   t o   p rint,   v ideo,   s ocial   m edia   a nd   w eb   f or   C amp   B eaverfork   a nd   o ther   p ublishing   u sed  

by   A rkansas   F ree   W ill   B aptist,   I nc,  

 

Parent/Guardian   S ignature_____________________________________________  

Date____________________