I certify that I am the parent or guardian of the Participant. In case of medical emergency, I understand that every effort will be made to contact the parent or guardian of the Participant. In the event that I cannot be reached, upon first attempt, at any of the emergency contacts that I provided, I hereby give permission for the physician selected by St. Xenia Camp to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for the Participant. I hereby certify that the Participant is covered by a medical insurance policy. In the event that any costs of care are not covered by a medical insurance policy, I hereby agree to be financially responsible for any such costs. Further, I hereby authorize medical dispensary care for the Participant and authorize treatment not considered routine to be referred to local physicians and medical facilities at my expense.

I give permission for the Participant to be transported in camp-operated vehicles for approved out-of-camp activities, for purposes of medical transport, and for the release of medical records in case of illness.

I expressly agree that all use of the Forest Acres and Saint Xenia Camp Facilities and the attendance and participation in any activities is undertaken at my and the Participant's sole-risk. I further agree that Forest Acres and/or Saint Xenia Camp, and its employees, volunteers, agents, officers, directors, and assignees, shall not be held liable for any claims, demands, injuries, damages or causes of legal action whatsoever to the Participant arising out of or related to the use of the facilities or the attendance at and participation in any activities. I and the Participant expressly and forever release and discharge the Forest Acres and Saint Xenia Camp, and its employees, volunteers, agents, officers, directors, and assignees, from any and all claims, demands injuries, damage, and actions or causes of actions, whether in negligence or otherwise, arising out of or related to the use of the Forest Acres and Saint Xenia Camp facilities and the attendance and participation in any activities.

Further, in light of the COVID-19 pandemic, I and the Participant acknowledge that Saint Xenia Camp will perform all reasonable and necessary precautions, as specifically outlined by Saint Xenia Camp. I agree that these precautions are reasonable and necessary. I and the Participant further acknowledge that some risk of COVID-19 transmission still exists despite any precautions. I and the Participant expressly assume the risk of transmission of COVID-19 arising out of or related to the use of the Forest Acres and Saint Xenia Camp facilities and the attendance and participation in any activities and expressly and forever release and discharge the Forest Acres and Saint Xenia Camp, and its employees, volunteers, agents, officers, directors, and assignees, from any and all claims, demands, injuries, damage, and actions or causes of actions, whether in negligence or otherwise, related to this risk.

In signing this form, I hereby certify that all information is correct.