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2017 Chesapean Outdoors Waterman Surf Camp
Informed Consent and Waiver Form 

 

 


 
 
 

Parent/Guardian:  Chesapean Outdoors makes every effort to ensure a safe, positive, and enriching experience for all campers. We focus on safety and accident prevention, and we are trained and certified in CPR/First Aid to promptly respond in the unlikely event that an incident occurs. Please read, sign, and date this form. Please e-mail this form back to matt@chesapean.com , along with the Emergency Medical Form no later than the start date of your child’s camp session. 

Acknowledgement of Risk:
I hereby acknowledge that I have voluntarily chosen to allow my child to attend Chesapean Outdoors Waterman Surf Camp. The activities in which my child may participate at camp may include, but are not limited to: games, exercise, paddlesports, aquatic activities, surfing, and outdoor activities
 
I understand the risks involved in these activities: I recognize that each camp activity involves risk of injury to my child and I agree to accept any and all risks associated with it. By voluntarily allowing my child to participate in camp activities and with the knowledge of the risks involved, I hereby agree to accept any and all inherent risks.
 
Hold Harmless
In consideration of allowing my child to participate in Chesapean Outdoors Waterman Surf Camp and to the fullest extent permitted by law, I agree to hold harmless Chesapean Outdoors, its employees, and its volunteers and assigns from and against all claims arising out of or resulting from my child’s participation in camp. I hereby voluntarily hold harmless and release Chesapean Outdoors, its trustees, officers, employees, agents and volunteers from any and all claims arising out of or incident to my child’s participation in Chesapean Outdoors Waterman Surf Camp, which may be made on behalf of me, my child, my personal representatives and my heir or assigns.
 
Child Will Abide By Rules and Regulations
I have instructed my child to cooperate and comply with all reasonable directions and instructions received from camp staff. I have reviewed the Camp Rules, Expectations, and Consequences outlined in the camp preparation package with my child. I understand that any violation of camp rules will result in consequences, and ultimately dismissal from camp. I understand that if my child is dismissed from the camp, I will not receive a refund for any unused portion of the pre-paid camp fee.
 
Commitment to Being Available
I commit to being available during camp hours (9am – 1pm) to answer a phone call from Chesapean Outdoors and its staff. I have provided a phone number to Chesapean Outdoors where I can be reached at any time during camp hours. I also commit to being available or making arrangements for my child to be picked up for any reason and at any time during camp hours (9am – 1pm).
 
Consent to Administer Non-Emergency First Aid
I understand and acknowledge that occasionally a non-emergency may develop which necessitates the administration of non-emergency First Aid to my child. Therefore, in the event of non-emergency injury or illness which necessitates the administration of non-emergency First Aid, I hereby authorize Chesapean Outdoors and its staff in charge of the Chesapean Outdoors Waterman Surf Camp to administer any necessary non-emergency First Aid. Non-emergency First Aid treatment may include, but is not limited to: cleaning, applying anti-biotic ointment to, and bandaging cuts or abrasions; removal of ticks and splinters; and applying an ice-pack to bites, stings, or an injury. The following substances may be used in the administration of non-emergency First Aid: water, ice pack, ACE bandage, antibacterial soap, alcohol swabs, anti-biotic ointment, and band-aids. No oral medication will be administered unless authorized and directed by the child’s parent/guardian. I understand that if I do not consent to the administration of non-emergency First Aid or to the administration of any of the substances listed above, I will give written notification to Chesapean Outdoors no later than seven business days before the camp session begins.
 
Consent to Administer Emergency First Aid
In the unlikely event of a life- or limb-threatening emergency, I give consent to Chesapean Outdoors and its staff to administer emergency First Aid as a first response until more advanced medical care is available. I understand that Chesapean Outdoors and its staff will use their best judgment, act in good faith, and will treat with the intention of not causing further harm.


Consent to Arrange Emergency Treatment
I understand and acknowledge that on rare occasions an emergency may develop which necessitates the administration of medical care, dental care, hospitalization, or surgery to my child. Therefore, in event of injury or illness to my child which necessitates emergency medical or dental care, I hereby authorize Chesapean Outdoors and its staff in charge of the Chesapean Outdoors Waterman Surf Camp to arrange any necessary emergency treatment including the administration of anesthetics and surgery to my child. I also understand that a parent/guardian will be contacted at the earliest possible moment in the event of an emergency relating to my child.
 
Medical, Dental, Health, and Insurance Responsibilities
I understand and acknowledge that Chesapean Outdoors cannot assume responsibility for determining the medical, dental, or health condition of my child. Therefore, I have consulted with a medical doctor and/or dentist, as I have deemed necessary, with regards to my child’s individual medical or dental issues or needs, and find my child physically and mentally fit to participate in the Chesapean Outdoors Waterman Surf Camp. If my child is required to receive medical, dental, or hospital services during camp, I am aware that Chesapean Outdoors cannot and does not assume legal responsibility for payment of such costs; rather, I hereby assure Chesapean Outdoors that I have assumed all risk and responsibility thereof and that my child has the necessary insurance to meet any and all needs for payment of these services during the Chesapean Outdoors Waterman Surf Camp.
  
I HAVE CAREFULLY READ THIS AGREEMENT. I FULLY UNDERSTAND ITS CONTENTS AND SIGN IT OF MY OWN FREE WILL. 
 
Dated: December 12, 2018

Please select who will be participating...
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Permission to Use Photograph or Likeness
​I hereby give my permission to Chesapean Outdoors to use my child's photographic image, in whole or in part, for camp-specific public information and for marketing activities at the discretion of Chesapean Outdoors. I understand that the photography remains the property of Chesapean Outdoors

Check this box if you do NOT give the above permission to use your child's photograph or likeness.

MEDICAL CONDITIONS:

ALLERGIES:

CURRENT MEDICATIONS:

FAMILY DOCTOR: *

DOCTOR'S PHONE:

ALTERNATE CONTACT'S NAME:

CELL PHONE:
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Permission to Use Photograph or Likeness
​I hereby give my permission to Chesapean Outdoors to use my child's photographic image, in whole or in part, for camp-specific public information and for marketing activities at the discretion of Chesapean Outdoors. I understand that the photography remains the property of Chesapean Outdoors

Check this box if you do NOT give the above permission to use your child's photograph or likeness.

MEDICAL CONDITIONS:

ALLERGIES:

CURRENT MEDICATIONS:

FAMILY DOCTOR: *

DOCTOR'S PHONE:

ALTERNATE CONTACT'S NAME:

CELL PHONE:
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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