As the Parent and
Legal Guardian of the specified camper, I request that in my absence the
above named minor be admitted to any hospital or medical facility for
diagnosis and treatment. I request and authorize physicians, dentists and staff
duly licensed as Doctors of Medicine or Doctors of Dentistry or other such
licensed technicians or nurses, to perform any diagnostic procedures, treatment
procedures, operative procedures and x-ray treatment of the above minor. I have
not been given a guarantee as to the results of the examination or treatment. I
authorize the hospital or medical facility to dispose of any specimen or tissue
taken from the above-named minor.
Acknowledgement of
Parish and/or School role in the camp:
The above-named minor
is a participant in Baroody Camps, Inc. and we hereby
acknowledge that this program may involve a variety of activities which may be
both physical and mental in nature. These activities are designed to be within
the limits of a person who is reasonably good health. The level of
participation in all programs and activities is at all times completely up to
my child. By electronically signing this waiver, I recognize the risk that my
child may suffer an emotional or physical injury or disability and release
Baroody Camps, Inc, its President, and it employees from all liability
associated with such risks. I give my child permission to participate in the
camps indicated above. I have no knowledge of any physical impairment that
would affect this camper from participating in the camps' Programs. I agree
that in case of accident while participating in these camps, I release the camp,
the camp director, and other educational facilities that may be used for camp
from any liability.
Liability coverage:
The Parish and/or
School is not furnishing and is not responsible for and assumes no liability in
connection with participation in this camp. The Parish and/or School is not
furnishing and is not responsible for and assumes no liability of guarantee or
assurance of safety of participant and/or the elimination of all risks from the
environment. The Parish and/or School is not furnishing and is not responsible
for and assumes no liability for the safety of personal property during
participation in the program. The Parish and/or School is not furnishing and is
not responsible for and assumes no liability for monitoring and/or control of
all the daily personal decisions choices and activities of the individual
participants. The Parish and/or School is not furnishing and is not responsible
for and assumes no liability for assumption of responsibility for the actions
of persons who are not volunteers or employees of the Parish and/or School or
otherwise engaged by the Parish and/or School, for events that are not part of
the program, or that are beyond the control of the Parish and/or the school and
its subcontractors. I voluntarily and without reservation and on behalf of
myself, my child who is signed up for this program, my heirs, and my estate,
hereby indemnify, defend and hold harmless the Parish and/or School, to include
but not limited to Baroody Camps, Inc. and all associated employees, the
Diocese of Arlington, the most Reverend Paul S. Loverde and his successors in office,
their officers and employees from any and all liability, loss damages, costs or
expenses which are sustained, incurred, or required arising out of mine or my
above noted child's actions in the course of the above program and activities.
Use of Vehicles:
I further acknowledge,
with regard to any personal vehicle driven by me or which I am a passenger in,
that in the event of an accident, there is no coverage afforded to me through Baroody
Camps, Inc. or the Diocesan Master Insurance Program for liability or physical
damage sustained to any vehicle involved or liability incurred by me while
operating my vehicle. I acknowledge that if I choose to park at any Baroody
Camps or Diocesan facility, I do so at my own risk.
Reimbursement of
Medical Expenses:
I recognize and
acknowledge there is no volunteer accident coverage nor is there any medical
payments coverage available to me or my participating child in order to
compensate me for expenses I incur from deductibles, co-payments, prescription
drugs, or medical services not covered through my own health insurance
provider(s) for any injury my child sustains as a result of participation in
the above mentioned camps. I agree that any medical coverage(s) I have will be
primary and under no circumstances will I seek any contribution from Baroody
Camps, Inc, it employees, its president, their insurer, the Diocese of
Arlington, or their insurer, for any medical expenses.
Informed Consent to
Medical Treatment:
In the event of an
injury, I hereby give Baroody Camps, Inc., its President, its employees full authority
to take whatever action they feel is warranted under the circumstances
regarding my child's health and safety, if I am not present to give informed
consent including but not limited to the application of emergency medical
procedures, the admittance to a hospital or the care of a medical professional
at my expense.
Safety:
I will hold
myself accountable for my child(ren)'s agreement to follow all procedures and
safety precautions set forth by Baroody Camps, Inc.
I freely execute this Acknowledgement with full knowledge of
its content.
