WATERMARKS CAMP, INC. MEDICAL CONSENT FORM / LIABILITY RELEASE

(TO BE FILLED OUT BY PARENT OR GUARDIAN)

1145 James River Road, Scottsville, Virginia  24590 | Phone (434) 286-4403 | Fax (434) 286-3549 | www.watermarkscamp.com

::ATTENTION::

PLEASE PAY CLOSE ATTENTION TO YOUR COMPUTER AUTO FILL FEATURE TO ENSURE YOUR CHILD'S INFORMATION IS CORRECT.

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CAMPER: (Child or Leader's information goes here)
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PARENT/GUARDIAN (if under 18 years of age):
HEALTH/MEDICAL:
Watermarks Has Permission to Administer:
EMERGENCY CONTACT:
​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. I understand that my child(ren) may be transported by bus, van or automobile to locations off the Watermarks campus as part of the program activities, and I hereby give my permission for my child(ren)’s transportation. I also grant permission for my child(ren) to receive emergency medical attention should I not be able to be contacted in a timely fashion.
SPECIFIED CONSENT:
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.
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:
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.  After campers are registered and confirmed by deposit, there are no cancellations or refunds.  

© 2020 Park Valley Church  |  4500 Waverly Farm Drive  |  Haymarket, VA 20169 

Questions? Contact us at info@parkvalleychurch.com or 571.261.2136

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