Loading...

Minor Staff Member Release Form

Authorization for Health Care:

I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

It is my intention that representatives of the camp be considered 'personal representatives' for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; to to provide information to the camp representatives to keep me informed of my child's health situation.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of camp.

By signing below, I authorize Camp Carl to administer any listed prescription medication(s) to my minor child.

I assume all risk, including risk of physical harm or death, associated with the administration of the medication(s). I agree to indemnify and hold the Camp Carl harmless from any liability, including the Camp Carl resulting directly or indirectly from the Camp Carl administering the medication(s) or failing to do so.

Authorization for Leaving Camp Property:

Camp Carl maintains a closed-campus policy for the safety and supervision of all campers and staff. Minors (staff members under 18 years of age) are not permitted to leave camp property while camp is in session (Sunday at 2:00pm - Friday at 6:00pm) except under the specific circumstances outlined below and with prior approval from Camp Carl leadership and formal consent from a parent or guardian.

Minors may only leave camp property under one of the following conditions unless approved otherwise:

1. Approved Time Off Requests

  • Must be pre-approved by Camp Carl leadership in accordance with time off request policies.
  • Requires formal consent from a parent or guardian for each instance of time off.

2. Official Camp Programming Events

  • Includes camp-supervised activities that take place off-site under the direction of authorized Camp Carl staff.
  • Examples may include, but are not limited to:
  • Attending a church service during staff training as a staff.
  • Programmed activities such as tubing or swimming at West Branch State Park.
  • Other programmed activities that require leaving camp property.

By signing below, I acknowledge and consent to my child’s participation in official camp-supervised off-site activities as described above. I understand and agree that:

  • All transportation will be provided or arranged by authorized Camp Carl personnel.
  • My child will remain under the supervision of authorized and trained camp staff or volunteers during all off-site trips.
  • Appropriate and necessary safety precautions will be taken during all off-site trips.
  • My child may be transported in vehicles operated by camp staff, volunteers, or approved third-party providers as deemed necessary by Camp Carl.
  • Participation in off-site activities carries inherent risks. I release Camp Carl, its staff, volunteers, and affiliated organizations from any liability, claims, or demands arising from these activities.
First Minor Summer Staff Name
First Name*
Last Name*
Phone*
First Minor Summer Staff Date of Birth*
Date of Birth
First Minor Summer Staff Signature*
Second Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Third Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Fourth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Fifth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Sixth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Seventh Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Eighth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Ninth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Tenth Minor Summer Staff Name
First Name*
Last Name*
Minor Summer Staff Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Insurance
Insurance Carrier*
Insurance Policy Number*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any Summer Staff who is a  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.



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!