Chapel Youth | Winter Camp '26 Medical/Participation Release

Your name *

Email address *

PARTICIPANT INFORMATION (TO BE COMPLETED BY PARTICIPANT OR AUTHORIZED GUARDIAN)

Name of Particpant (Child or Student) *

Should match name above.

Household members

Please add Parent(s) name and info here. Birthdate is requested only to have a age attached to your profile.

Name of Parents/Gardians *

Address *

Phone number *

Name of Emergency Contact *

Emergency Contact Phone Number *

List of Allergies or Medical Conditions *

Camano Chapel Participant Medical Information

All medications must be in original prescription or OTC containers with specific directions for dosage and frequency, or it will not be accepted by the person(s) registering the student.

CHECK ALL THAT APPLY!

This child takes medication(s) and will self-medicate.

I understand that the child will be required to turn all medication(s) (clearly labeled) over to the designated adult. I further understand that it will be this child’s responsibility to present himself/herself at a location designated for receiving medication(s) at frequencies/times listed below. I understand that the adult to whom this child surrenders the medication may have no medical training and will not measure dosages. This child will return the medication(s) to the adult after he/she self medicates. At the conclusion of the event/camp it will be this child’s responsibility to pick up remaining medication.

This child can self medicate and has permission to keep their medications with them.

(Example: Epi-pen, inhaler, etc)

This child takes medication but is unable to self-medicate.

No medication of any type whether prescription or nonprescription may be administered to this child unless the situation is life-threatening & emergency treatment is required.

I grant permission for the following nonprescription medication to be given to this child, (Excluding medication listed that causes allergic reaction).

Is sponsor authorized to approve medical treatment? *

Yes

Has child recently been exposed to contagious disease or condition such as mumps, measles, chicken pox, etc? If so, date and disease/condition:

Is participant covered by personal/family medical insurance? *

Yes

PARTICIPATION AGREEMENT

I agree *

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.
In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor.

I consent to my student being photographed at this event for use in promotional materials and/or social media posts. *

Yes

I acknowledge that my legal name below serves as my signature and *

I have READ and UNDERSTAND all the information in the parcitipate agreement above.

Please type your full Legal Name (this serves as your signature): *