Midsouth Christian Leadership Camp Parental Consent and Release of Liability
Please Provide All Information Requested - Campers 18 or older may complete their own consent. Please fill out one consent form per camper.
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Email *
First and Last Name of Camper  *
Camper's Date of Birth *
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Camp Physical Location *
Dates Camper will Attend Camp *
Consent to Attend Camp - I hereby give permission for above camper to attend and participate at Dixieland Leadership Camp *
Consent to Medical Treatment -  If Camper experiences an injury or illness, or has other medical needs, I authorize the Camp’s employees, volunteers, and agents to make such arrangements for Camper’s health and safety, including but not limited to first aid, emergency medical care, ambulance or other transportation to a hospital, medical office, or clinic, testing and examination, and hospital care, and other medical care and treatment (including dental care) as they feel are appropriate in the circumstances. I further agree that I am fully responsible to pay all charges and expenses relating to such care, transportation and treatment and I hereby fully release DLCI and its directors, officers, employees, volunteers and agents from any claims, including claims for medical charges, prescription costs and other expense, I might have as a result of such care, transportation and treatment. My signature below also serves to indicate my willingness for my Health Insurance Company (please provide details in the Medical Information section) to be billed for any and all medical fees and services should they be needed. I agree that I will pay all charges and expenses not covered by insurance. *
Medical Insurance Information (You must bring a copy of the FRONT AND BACK of your insurance card with you to camp.  It must be a copy and not the original card.  Each camper must have their own copy) *
Medical Insurance Company as listed on Card.  Please enter "N/A" if no insurance. *
Policy Number as listed on Card.  Please enter "N/A" if no insurance. *
Insured's Name Please enter "N/A" if no insurance *
Primary Care Doctor's Name - Please enter "N/A" if no Primary Care Doctor.  *
Primary Care Doctor's Phone Number  - Please enter "N/A" if no Primary Care Doctor.  *
Date of last Tetanus shot: *
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List any medical or food allergies of Camper.  Enter "none" if applicable.  If yes, please provide details and reaction.   *
Will Camper be under an medication while at camp? If yes please provide medications and dosages.  If no Please enter "No" *
All medications must be in original containers with prescription information and given to the camp nurse UPON CHECK IN.  ALL CAMPERS MUST CHECK IN WITH CAMP NURSE REGARDLESS OF MEDICATION NEEDS.  *
The camp nurse has my permission to provide Camper with non-prescription medicines as deemed necessary.   *
Please list any OTC meds that should NOT be given to camper.   
Does Camper have any physical condition or limitations that would restrict participation in any camp activities?   *
If your answer was yes above, please describe campers physical limitations.  
Release of Liability - Prior to Camper’s participation in Camp activities, I acknowledge that involvement of Camper in the Camp may involve risk of property damage and of personal injury, illness or even death of Camper, including but not limited to the risks arising from transportation–related activities, recreational activities, accidents in the outdoors and rustic facilities, adverse weather conditions, and injuries and illness as a result of food-borne illnesses and allergic reactions. In addition, I understand that there may be other risks inherent in Camp activities of which I may not be presently aware.

By Clicking yes in this Parental Consent and Release of Liability, I warrant that Camper is fully capable of safely participating in all Camp activities, including transporting to group activities and swimming, and I expressly assume all risks of Camper’s participation, whether such risks are known or unknown to me at this time. I further generally release Dixieland Leadership Camp, Inc. and its directors, officers, employees, volunteers, and agents, and other campers at the Camp, from any and all claims that I or Camper may have against any of them as a result of property damage or personal injury, illness or death of Camper as a result of participation in Camp activities, whether on or off Camp grounds. I agree that this release includes the ordinary, special and inherent risks described above, and other risks that I may not foresee or be aware of at this time. This Release of Liability is given on behalf of myself, Camper, and the heirs, family, estate, administrators, executors, personal representatives and assigns of me and Camper. 

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Other Releases and Acknowledgements

Bubble Soccer - Waiver of Liability, Assumption of Risk, and Indemnity Agreement*

*Waiver: *In consideration of being permitted to participate in any way in “Bubble Soccer” or “Bubble Ball,” hereinafter called "The Activity", I, for my child, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Dixieland Leadership Camp or Ft. Bluff Camp, its officers, employees, and agents from any and all liability from any and all claims, including the negligence of Dixieland Leadership Camp and Ft. Bluff Camp, its officers, employees and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.

*Assumption of Risks: *Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks include 1) minor injuries such as scratches, bruises, and sprains 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis and death.

Other risks include, but are not limited to, slips, falls, contact with other participants, negligent or wanton acts of other participants, any defects or condition of premises or equipment, insects or wild animals, the effects of the weather including high heat, cold temperatures, storms, and/or humidity.

*I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my child’s participation is voluntary and that I knowingly assume all such risks.* 

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*Indemnification and Hold Harmless: *I also agree to INDEMNIFY AND HOLD Dixieland Leadership Camp and Manderley Christian Camp, HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.

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*Rules and authority:*  Camper agrees to abide by the rules and instructions of the referee at all times during the Activity, including but not limited to the referee stopping my participation of the activity at any time for any reason.

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I understand that, while Camper is participating in Camp activities, photographs, film, audio recordings and videotape of Camper may be taken for use in brochures, videos, releases to the press, and various DLC publications and other work product. I do hereby irrevocably grant DLC permission to record, display and/or reproduce my child’s name, likeness and voice on audio and/or video tape, film or other media, to edit and otherwise modify such media at its discretion, to incorporate the media into any work product, and to use or authorize the use of such media or any portion thereof in any manner or media or by any means, methods or technologies now known or hereafter to be known. 

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I understand that DLC does not provide transportation to or from the Dixieland Leadership Camp program and do hereby take responsibility for either providing or arranging for transportation of Camper, and for ensuring that Camper will arrive and depart by the scheduled dates and times.

I will ensure Camper only brings clothing that adheres to the Camp Dress Code or similar policy included as part of this package or to be sent in the acceptance package. If Camper fails to abide by established rules, standards of conduct and/or Camp Dress Code, Dixieland Leadership Camp staff reserve the right to send Camper home. If it becomes necessary to send Camper home, I hereby agree to provide transportation or to make travel arrangements for Camper and to assume the cost of these expenses.

To the extent any provision of this document is found to be unenforceable, such provision shall be deemed severable and shall not affect the enforceability of any other portion of this document, and shall be reformed to be in compliance with the law and construed to most nearly reflect the intent of the parties.

I represent and warrant that I am a parent or legal guardian of the Camper named above or am the camper and over the age of 18 and have the full power and authority to enter into this Parental Consent and Release of Liability on behalf of the Camper. By signing below, I acknowledge that this document has been read and understood by me, and also represent that all information provided is accurate. Each legally responsible parent/guardian is required to authorize below.  

 

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By agreeing below, , I ALSO agree I have read the Policies and Procedures of DLC and the DLC Survival Kit and understand failure to comply or any violation is a serious matter which will require careful evaluation to determine if the camper may remain at DLC. 

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First and Last Name of Parent or Guardian Filling out this form.  (Or if you are a camper over the age of 18, enter your name here)

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Daytime Cell number of Person filling out this form.  Must be able to receive text message authorization.   Must be parental guardian or camper over the age of 18 (888-888-8888 format please).

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