We want this summer camp experience to be safe and healthy for all particpants. To assist us in the event of an accident or illness, it is important that we have the following information:

Past Medical History (Check All Conditions That Apply)

Allergies & Special Needs (Please Describe Details, Proper Treatement, etc. for Any Conditions Listed Below)

I give permission to the Camp Nurse / First Aid Person to administer to my son/daughter or camper attending Summer Camp, Tylenol if needed.

NOTE: Summer Camp personnel will CHECK ALL campers attending Summer Camp to check for head lice. If head lice is discovered on a child, they be be sent home immediately.

By SELECTING the TERMS & AGREEMENTS BOX BELOW;

I, the parent / guardian of the above named child/camper, release 1st Presbyterian Church of Jacksonville and its affiliates from any liability resulting from his / her participation in Summer Camp Event.

In the event of an emergency, I understand that every reasonable effort will be made to contact me. If I cannot be contacted, I give my permission to the physician selected by the Camp Director and Nurse / First Aid Person to hospitalize and secure treatment (including surgery) for my child.

I, do hereby grant permission for my son/daughter or camper, named above, to attend Summer Camp Event. In order that my son/daughter or camper may receive the proper medical treatment in the event that he/she may sustain injury or illness during the camp, I hereby authorize the camp staff to obtain or provide medical treatment for my son/daughter or camper for such injury or illness during the camp, and I hereby hold the camp staff and sponsoring organization(s), as well as its representatives, harmless in the exercise of this authority.

I further understand that there is always a possibility that my my son/daughter or camper may sustain physical illness or injury while at the camp. If this occurs, I hereby authorize the camp staff and representatives to refer my son/daughter or camper to a medical treatment center (hospital, etc.). I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness or injury that he/she may sustain during the camp.

Understanding that there is always a possibility that my son/daughter or camper may sustain physical illness or injury, I acknowledge and understand that my child/camper is assuming the risk of such physical illness or injury by his/her participation, and I further release the sponsoring organization and its representatives from any claims for personal illness or injury that my son/daughter or camper may sustain during the camp. I further acknowledge and understand that my son/daughter or camper will be responsible for his/her failure to abide by the rules and regulations of the camp.

I understand that my Registration Fee can not be refunded after July 1, 2019, as there are fixed costs associated with hosting this event.

Partial Scholarships may be awarded depending on funding and specific needs presented. Please email Michelle Wallman ([email protected]) to request scholarship funding (code) and describe your specific need or situation.