SUMMER CAMP WAIVER TEMPLATE Summer Camp Waiver TEMPLATE "*" indicates required fields Contact DetailsParent/Guardian Name* First Last Alternate Parent/Guardian Name*Applicable if you have a spouse that will occasionally do pickup/drop off First Last Email* Enter Email Confirm Email Parent / Guardian Phone*Camper Home Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code WaiverConsent*I understand and agree that Friends of the Rappahannock (“FOR”) Volunteer/Participant activities are entirely voluntary on my part and may involve potentially strenuous and hazardous activities and there are risks of accidents arising out of these activities. I have no expectation of compensation for these activities. I acknowledge that I currently have no known mental or physical condition that would impair my capability for full participation as intended or expected. I expressly assume all risks of injury, bodily harm or property damage arising out of my activities with FOR. I further acknowledge that I am responsible for my own insurance coverage and FOR has no liability or responsibility to me for any medical, health or other benefits or compensation. I release and forever discharge FOR, its successors and assigns, employees, officers, directors and agents, and any sponsoring organizations from any and all claims, liabilities and demands of any kind or nature, in law or equity, arising out of my activities with FOR, including any claims for bodily injury, death, illness or property damage occurring while engaged in my activities with FOR, even if caused by the negligence or reckless conduct of a FOR employee or Volunteer/Participant. I further agree to indemnify and hold harmless FOR, its successors and assigns, employees, officers, directors and agents, and any sponsoring organizations in connection with any of the foregoing. In case of emergency or accident, I give permission for any first aid treatment or other medical services rendered on my behalf, and release FOR from any and all liability in connection with any medical services. I agree to be the responsible party for all medical expenses incurred on my behalf. I agree to the above conditionsEssential Eligibility Criteria*I understand that for my child to SAFELY participate in this camp, they must meet ALL Essential Eligibility Criteria listed below. – Breathe independently (i.e., not require medical devices to sustain breathing) – Independently maintain sealed airway passages while underwater – Independently hold head upright without neck/head support – Manage personal care independently or with the assistance of a companion – Manage personal mobility independently or with a reasonable amount of assistance – Follow instructions and effectively communicate independently or with assistance of a companion – Independently turn from face-down to face-up and remain floating face up while wearing a properly fitted life jacket – Get on / off or in/out of a paddlecraft independently or with a reasonable amount of assistance – Independently get out and from under a capsized paddlecraft – Remount or reenter the paddlecraft following a deep water capsize independently or with a reasonable amount of assistance My child meets all of the above criteria.Photo ReleaseI agree to grant FOR the right and unrestricted permission concerning any photographs that FOR has taken or may take of my child(ren) or in which my child(ren) may be included with others, to use, reuse, publish, and republish the photographs in whole or in part, individually or in connection with other material, in any and all media now or hereafter known, including the internet, and for any purpose whatsoever, without restriction as to alteration; and to use my name in connection with any use if FOR so chooses. I grant FOR all right, title and interest in any photographs, images, video or other media recordings taken by me or of my child(ren) or their likeness or voice in connection with my activities with FOR. I release and discharge FOR from any and all claims and demands that may arise out of or in connection with the use of the photographs, including without limitation any and all claims for libel or violation of any right of publicity or privacy. I agreeCamper InformationCamper Name* First Nickname (if different from First Name) Last Gender*MaleFemaleNon-binaryPrefer Not to AnswerRising Grade Level*This is the grade level the camper will be attending Fall 2026First GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth GradeNinth GradeCamper Date of Birth* Month Day Year Medical History*Any surgeries or essential medical details we should need be aware of. Allergies*First Aid*This camp is outside and sometimes little injuries do occur such as bee stings or scraped knees. This is a precaution and parents are always called when an incident occurs. YES to Band-Aids, Benadryl, or TylenolYES to Band-Aids, but NO to Benadryl or TylenolNo First-Aid without my consentIs there anything else we should know about your camper?Will they have siblings or friends in camp with them? Are they deadly afraid of spiders/ snakes? Do they have a favorite thing that helps them make friends quickly?Emergency ContactThis is the individual who should be called if your camper is sick, injured, etc. Emergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship*What is the Emergency Contact’s Relationship to the Camper?ParentOlder Sibling (must be over 18)GrandparentGuardianNeighborFriendOTHERCamper Pick UpFor anyone who is not listed as the Parent/Guardian or Alternate Parent/Guardian who will be picking up your camper.Name First Last PhoneRelationshipWhat is the Relationship to the Camper?ParentOlder Sibling (must be over 18)GrandparentGuardianNeighborFriendOTHERConsent I agree that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.Parent Guardian Electronic Signature*I am the parent or legal guardian of the Volunteer/Participant. I have read this form and understand and acknowledge the risks and liability. I understand that by signing this form, I am giving up legal rights and remedies.How did you hear about this camp?Social MediaGoogle/ WebsiteWord of MouthRefer a FriendPast ParticipantOther
