Summer Camp - Permissions Form
Email *
Child Name *
Child Grade *
Parent Name *
Permission for Medical Treatment and Administration of Medications                                                                          1. I acknowledge that my child may need emergency medical treatment in school or when participating in school activities, athletics, and field trips. I authorize Mount Pisgah Christian School (MPCS), through its faculty and/or staff, to provide first aid and medical treatment deemed appropriate for the circumstances. 2. I consent for MPCS to seek medical services, without prior notification to me, should the circumstances warrant it. I give permission for my child to be treated at a hospital or other medical facility.  3. I request that MPCS, through its designated authority, administer the over-the-counter medications as I have indicated for my student on the Medical Information form.  4. I consent that MPCS may administer prescription and/or non-prescription medications. Verbal permission and an Authorization to Administer Medication Treatment must be provided to administer such medications. In addition, I accept that medications must be in their original container.  5. I release, and agree to hold harmless and indemnify MPCS, and any persons administering medical treatment on behalf of MPCS, for liability for providing medical treatment or medications. *
Required
Provision of Medical and Insurance Information:               1. I acknowledge my responsibility to inform MPCS of any allergies, medical or physical conditions, and/or communicable diseases that my child may have, or may develop through the school year.                              2. I acknowledge that the medical information provided will be kept with the school nurse and will be shared with faculty and staff as needed, including teachers, coaches and or activity chaperones.              3. I acknowledge that the responsibility of providing medical insurance rests with me. A copy of my child's insurance information has been provided to the school. *
Required
1. I assume all risks for my child participating in athletics or school-related activities, including any risk associated with special medical needs or conditions of my child.2. I release the Board of Trustees, MPCS, faculty and staff, coaches and designated chaperones from liability in administering medications and providing first aid and medical treatment for my child.3. I acknowledge that physical activity and sports carry a risk of injury and that my child can be injured despite the best efforts to provide a safe experience. I recognize that, on rare occasions, these injuries can be so severe as to result in total disability, paralysis, or even death.4. I release and agree to hold harmless and indemnify MPCS, and any persons participating on behalf of MPCS, for liability associated with school activities including but not exclusive to, athletics and team sports, physical education classes, field days, field trips, travel, and school retreats.5. I am fully aware of the risks associated with me and/or my child or ward returning to campus during the COVID-19 pandemic, including without limitation the risk that my child or ward could contract COVID-19 or other diseases which could result in a serious medical condition requiring medical treatment in a hospital or could possibly lead to death. I, hereby, forever release, waive, relinquish, and discharge Mount Pisgah Christian School, along with its Board of Trustees, Faculty & Staff, and/or other representatives, and their successors and assigns (collectively the "School"), from any and all claims, demands, liabilities, rights, damages, expenses, and causes of action of whatever kind or nature, and other losses of any kind, whether known or unknown, foreseen or unforeseen, as a result of me and/or my child or ward visiting or attending the School and contracting COVID-19 or any other disease, including claims based on alleged negligence of the School or School Representatives or any other person. *
Required
PUBLICITY AGREEMENT: I grant permission for MPCS to display my child's achievements or school activities, use or publicly display my/my child's photograph, video, audio clip, name, age, and grade on the MPCS website(s), or school social media (such as Facebook, Twitter, Instagram or similar), or in other official MPCS publications without further notice for any purpose deemed acceptable to MPCS. *
Required
A copy of your responses will be emailed to the address you provided.
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