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MEDICAL DISPERSION AUTHORIZATION

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LIABILITY FORM

 

 

 

TODAY'S DATE: January 18, 2020

ROYAL RIDGES RETREAT - LIABILITY FORM
PARTICIPATION AGREEMENT, RELEASE AND ACKNOWLEDGEMENT OF RISK

In consideration of the services of Royal Ridges Retreat, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as RRR) I hereby agree to release and discharge RRR, on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that my participation in horseback riding, challenge course, paintball, and other activities led or sponsored by RRR entails known and unanticipated risks which could result in physical or emotional injury, paralysis, death or damage to myself, to property, or to third parties. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity. I further understand that RRR programs and activities are based on the participation by choice and challenge by choice principles. At any time I and/or my group are free to withdraw from participation in the activity and its potential for the risks involved.

The risks include, but are not limited to:slips, falls and falling; rope burns; pinches, scrapes, bruises, twists and jolts that could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more severe life threatening hazards. During an activity, there may be contact with plants, animals, or insects that could create hazards such as kicks, bites, stings, allergies, and associated disease. Furthermore, RRR Staff Members have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of participants emotional stability, ability to handle stressful situation, physical fitness or abilities; they might misjudge the weather, and horses, which by their very nature are unpredictable.

2. I expressly agree and promise to accept and assume all risks existing in the activity. My participation in any activity sponsored by RRR is purely voluntary, and I elect to participate in spite of the risks.

3. I hereby voluntarily release, forever discharge and agree to indemnify, and to hold harmless RRR from any and all claims, demands or causes of action; which are in any way connected with participation in any activity, or my use of RRRs equipment or facilities, including any such claims which allege negligent acts or omissions of RRR.

4. Should RRR, or anyone acting on their behalf, be required to incur attorneys fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or in the alternative, I agree to bear the costs of such injury or damage to myself. I further certify that I have no medical or physical conditions, which would interfere with my safety in this activity; therefore, I am willing to assumeand bear the cost ofall risks that may be created, directly or indirectly by any such condition.

6. In the event that I file a lawsuit against RRR, I agree to do so solely in the state of Washington; and I further agree, that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state.

7. When riding a horse, participating in our high ropes course and/or climbing wall, a helmet must be worn at all times.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in any RRR activity, I may be found by a court of law to have waived my right to maintain a lawsuit against RRR on the basis of any claim from which I have released them herein.

 

First Camper's Name

First Name*

Last Name*

Phone*
First Camper's Date of Birth*
First Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
First Camper's Signature*
Second Camper's Name

First Name*

Last Name*
Second Camper's Date of Birth*
Second Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Third Camper's Name

First Name*

Last Name*
Third Camper's Date of Birth*
Third Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Fourth Camper's Name

First Name*

Last Name*
Fourth Camper's Date of Birth*
Fourth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Fifth Camper's Name

First Name*

Last Name*
Fifth Camper's Date of Birth*
Fifth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Sixth Camper's Name

First Name*

Last Name*
Sixth Camper's Date of Birth*
Sixth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Seventh Camper's Name

First Name*

Last Name*
Seventh Camper's Date of Birth*
Seventh Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Eighth Camper's Name

First Name*

Last Name*
Eighth Camper's Date of Birth*
Eighth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Ninth Camper's Name

First Name*

Last Name*
Ninth Camper's Date of Birth*
Ninth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Tenth Camper's Name

First Name*

Last Name*
Tenth Camper's Date of Birth*
Tenth Camper's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Camper's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
PICTURE RELEASE
I authorize use of photos or video taken of my child for promotional purposes. I have had sufficient opportunity to read this entire document. I have read and understand it, and agree to be bound by its terms.*
Yes
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

This section is to ask your permission to give your child medication. Please check the appropriate boxes and sign the bottom. All medications will be given under the direction of our Camp Nurse. Please check box if we may give your child these medications WITHOUT your permission. Leave unmarked if you would like us to ask your permission before dispensing medication, regardless of the urgency.

Oral Medications: (please check all that apply)

Benadryl (anti-histamine)
Children's Motrin
Children's Tylenol (anti-inflammatory)
Cough Drops
Cough Syrup
Day Quil /Night Quil
Ibuprofen (non-aspirin)
Maalox
Sudafed
Tums
None of the Above

Ointment Medications: (please check all that apply)

Caladryl (anti-histamine)
Benadryl (anti-histamine)
Hydrocortisone Creams
Triple Antibiotic Ointment
Burn relief
Vicks
Sunscreen
Bactine
None of the Above

Emergency Medications: (please check all that apply)

Epi-Pens (0.15 mg of epinephrine)
Eye Wash (Saline Solution)
None of the Above

Participant's Health Report


Special Dietary Needs: i.e. Gluten free, dairy free, nut allergy, etc. NOTE: If this person is attending a Resident Camp you MUST go to kitchen and talk with the cook when you deliver your camper. (please leave blank if not applicable)

Health Problems: (please leave blank if not applicable)

Drug, Allergies or Other Allergic Reactions: (please leave blank if non applicable)
Status of Tetanus vaccination: current?*
No
Yes

Approximate date of last shot (if known):

Regular Medications: (please leave blank if no medications)
Will the participant need assistance in scheduling or dispensing of any medications?*
No
Yes

If yes, please explain:

Instructions for Leftover Medications:

Activity Restrictions:

Medical Insurance Carrier and Policy #:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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