The information you provide will be in the strictest confidence. It will be kept on file in our health binder or carried by the camp director when your child travels on the campus with one of our camp groups.
Does your child have any allergic reactions to sunscreen?
May we serve your child good and non alcoholic beverages?
If your child must take medication while at camp, please note
here. All medications must be in their origincal containers and
be appropriately labeled. Please do not give your child's
medication to them to bring to camp; medications must be received
and held by the camp office or with the camp director.
Is your child up to date on all state required immunizations
Is the participant covered by family medical/hospital insurance?
Authorization of Consent
(I)(We), the undersigned parent(s) of my child, a minor,
do hereby authorize any hospital for the undersigned to consent
to any X-Ray examinations, anesthetic, medical or surgical
diagnosis or treatment, or hospital care which is deemed
advisable by, and is to be rendered under the genereal or special
supervision of, any physician and/ or surgeon licensed under the
provisions of the Medical Practices Act. It is understood that
this authorization is given in advance of any specific diagnosis,
treatment or hospital care to provide authority and power on the
part of our aforesaid agent(s) to give specific consent to any
and all such diagnosis, treatment or hospital care which
aforementioned physician, dentist and/or surgeon in the excercise
of his/her best judgement, may deem advisable.
These authorizations shall remain effective until Date here,
unless sooner revoked in writing delivered to said agent(s).
To the extent allowed by law, I, the undersigned am the
parent/guardian of the individual(s) named below and shall hold
harmless, indemnify, and defend Dream Keepers, Inc the trustees
of Dream Keepers, IC and the officers, employess, volunteers,
agents and actors of each of them from and against any and all
liability, loss, damage, expense, cost of every nature, and
causes of actions arising out of or in connection with any
negligence in the performance if this agreement. It is further
understood and agreed that this waiver, release and assumption of
risk to be binding on my heirs and assigns. I also release Dream
Keeper, Inc. of liability for any claims that may arise out of
acitivity. Dream Keepers, Inc. also reserves the right to remove
participants from the program if they present a threat to the
children or if they abuse the privilege of the mission statement
of Dream Keepers, Inc, I also understand that participation in
the program can cause servere injury or death and I have taken
care to enroll at the level of his/her/my/our physical abilities
and/or medical conditions. I hereby grant permission to Dream
Keepers, Inc. to take my photo while participating in the
activities to use for publicity. One parent/guardian must sign
for all minors.
I have read this entire Informed consent Agreement. I fully
understand it and I agree to be legally bound by it.