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Watermarks Camp Liability Release Form - MS003

Camper Information

Name:	Dates Attending: June 19-23, 2023
Address:	State:	ZIP:
Date of Birth:	Age:	Entering Grade:	Gender:
Are you coming as an individual or with a group?	GROUP
Name of Group	CORNERSTONE CHAPEL

Parent/Guardian Information

Name:	Home Phone:
Mother's Daytime Phone:	Cell Phone:
Father's Daytime Phone:	Cell Phone:

Health/Medical

Health/Medical Problems:
Drug/Food Allergies:
Last Tetanus:	Regular Medications:
Activity Restrictions:
Health/Medical Problems:
Family Doctor:	Phone:
Insurance Name:	Phone:
Policy Holder:	Birthdate of Policy Holder:
Policy Number:
Watermarks has the permission to administer: Ibuprofen Tylenol Advil Neosporin

Emergency Contact

Name:

Phone:

Relation:

If there are any activities that are known that the parent does not want their student to participate in or any prior injuries that could limit students activities or experience please state below:

The undersigned hereby acknowledges that there is risk in simply attending and/or participating in activities at Watermarks Camp. Watermarks will not be held responsible for any disease, sickness, injury or loss experienced during, before or after any event at Watermarks, including but not limited to COVID-19. I understand that my child(ren) may be transported by bus, van or automobile to locations on the Watermarks campus as part of the program activities, and I hereby give my permission for my child(ren)’s transportation. I grant permission for my child(ren) to receive emergency medical attention should I not be able to be contacted in a timely fashion.

INITIAL

The undersigned hereby acknowledges that the program(s) in which I have enrolled my child(ren) involves physical activity and exercise that carries some inherent health risks and risks of injury and I hereby assume those risks in enrolling my child(ren) in the program. By signing below, I grant permission for my child to participate in activities provided by and located at Watermarks Camp. If I do not wish for my child to participate in any activity, it is my responsibility to inform my leader or Watermarks Camp prior to my child’s arrival.

INITIAL

I, the undersigned, do hereby consent to the use by Watermarks Camp of my child’s image or voice in any video, photograph or audio tape used for fundraising, advertising, publicity, or any other purpose on behalf of Watermarks Camp. I also confirm that Watermarks Camp and staff are not responsible for loss or damage of any personal items brought to camp.

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Timestamp

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April 14, 2021 10:53 am EDT

Watermarks Camp Liability Release Form - MS003 Uploaded by Cornerstone Chapel - edocs@cornerstonechapel.net IP 107.77.203.33

April 14, 2021 10:58 am EDT

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 75.75.19.63

April 22, 2021 9:22 am EDT

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.142.42

April 1, 2022 10:56 am EDT

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.196.138.191

May 4, 2022 5:27 pm EDT

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 174.216.179.198

March 15, 2023 3:56 pm EDT

Middle School - middleschool@cornerstonechapel.net added by Cornerstone Chapel - edocs@cornerstonechapel.net as a CC'd Recipient Ip: 107.77.202.150