Summer Camp Liability/Waiver & Photo Consent Form Please complete: 2018 Summer Camp Liability Waiver and Photo/Video Consent Form This Liability Waiver and Photo Consent Form will be kept on file and apply to your child(ren)'s participation in Camps at Holy Rosary. We recommend that you complete this form for any child you have that is registering for this session or that will possibly register for a future season. Otherwise, any new children registered in future Camp sessions not listed on this form will require a separate form submitted for them. Number of Camp Participants*Please enter a value between 1 and 6.Participant Name:* First Last Participant's Birthdate:* MM DD YYYY 2nd Participant Name:* First Last 2nd Participant's Birthdate:* MM DD YYYY 3rd Participant Name:* First Last 3rd Participant's Birthdate:* MM DD YYYY 4th Participant Name:* First Last 4th Participant's Birthdate:* MM DD YYYY 5th Participant Name:* First Last 5th Participant's Birthdate:* MM DD YYYY 6th Participant Name:* First Last 6th Participant's Birthdate:* MM DD YYYY Primary Home Address* Street Address City ZIP / Postal Code Parent Name(s):Parent Mobile Phone 1:*Parent Mobile Phone 2 (Optional):Liability Waiver:* I grant permission for my child(ren) to participate in Holy Rosary Summer Camps. As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor participant(s). * I agree on behalf of myself, my child(ren)/participant(s) named herein, or our heirs, successors and assigns, to hold harmless and de- fend Holy Rosary Summer Camp instructors, Holy Rosary Parish, Holy Rosary School, and the Corporation of the Catholic Archbishop of Seattle, chaperones, or representatives associated with the Holy Rosary Summer Camp organization, from any and all actions, claims, demands, damages, costs, expenses and all consequential damage arising from or in connection with my child(ren) participating in SunDance or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the organization, its officers, directors and agents, and the Corporation of the Catholic Archbishop of Seattle, chaperones, or representatives associated with the event for reasonable attorney’s fees and expenses arising therewith. Medical Matters* I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact: Name:* First Last Relationship:*Mobile Phone:*Family Doctor:*Phone:*Family Health Plan Carrier:Policy #:Specific Medical Information(The organization will take reasonable care to see that the following information will be held in confidence): Allergic reactions (medications, foods, plants, insects, etc.):Immunizations– date of last tetanus/diphtheria immunization:Does child have a medically prescribed diet?Any physical limitations?Is child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, bedwetting, fainting?Has/have your child(ren) recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc.* Yes No If so, date and disease or condition:*You should be aware of these special medical conditions of my child:Photograph & Video Consent From time to time, pictures and video may be taken of participants involved with SunDance. We would like to able to use these photographs and videos for flyers, parish and diocesan publications, and the school or ministry website. Names will not be posted unless written authorization is given by the student and parent/guardian, and then only first names will be used. If there are concerns about pictures or videos posted on the website, please contact the organization or webmaster, and they will promptly be removed. * I give full consent, without limitation or reservation, to Holy Rosary Parish, Holy Rosary School, to publish any photograph or video in which the above named participant(s) appears while participating in any activity associated with SunDance. There will be no compensation for use of any photograph or video at the time of publication or in the future. I understand that should I choose to revoke this permission, the revocation is not effective until I have provided my revocation in writing to SunDance. I understand that revocation of permission will not include any past photo or video of named participant(s) that have already been used for above purposes. I do not give photograph or video consent for my child(ren) SignatureName of Parent Signing Liability Waiver & Photo/Video Consent:* First Last Parent Email:*
