Camp Reynal - Camper Application

Camp Reynal 2023

Camper Application
Application Deadline: March 31, 2023

Camp Dates: Sunday, May 28, 2023 - Friday, June 2, 2023

It will approximately take 15-20 minutes to complete the application. You will not be able to save your work mid-way through the application, so please have the following information available prior to starting the application process:

Please note a few things:

Your application is NOT considered complete until ALL sections are filled out/signed and all applicable documents are uploaded.

Suggestion: Please download/print the Primary Treating Physician Form and have your child's PCP complete it before starting this application (see link below). Otherwise, complete this application and email a scanned copy to campreynal@gmail.com. The application will be considered incomplete without the assessment.

To apply to participate in Camp Reynal, the parent or legal guardian must complete and return this Application Packet. The Application Packet must include:
- A complete and accurate Camper Application, containing all required information and attachments signed by the applicant’s parent or legal guardian.
- A Completed Medical Background Form.
- An Acknowledgement of Behavior Policy Form signed by the applicant and parent or legal guardian.
- A Conditions of Participation Form signed by the applicant’s parent or legal guardian.
- An Assessment by Primary Treating Physician Form, completed and signed by Physician. CLICK HERE TO OBTAIN THE FORM
  - *Cooks patients* Please disregard this step since your nephrology nurse will complete this form on your behalf.
- A copy of the applicant’s current health insurance card or other documentation of the applicant’s enrollment in health insurance coverage.
- A picture of the applicant for identification purposes.
Are you ready to begin? Click next!

General Information
Camper Name*

First NameMiddle NameLast Name
Prefers to be called:
Are you a Camp Reynal sibling?*

YesNo
Camp Reynal Sibling Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Camper's Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Cell Number

Area CodePhone Number
Parent/Guardian Home Number

Area CodePhone Number
Parent's E-mail Address*
example@example.com
Camper Height (inches)*
Camper Weight (pounds)*
T-Shirt Size*

Parent/Guardian Information
Camper lives with*

MotherFatherBoth
Do camper's parent/guardian live together?*

YesNo
Are there any custody or visitation restrictions?*

YesNo
If yes, please describe:

Parent/Guardian Information

Please provide information for both parents/guardians.

If information is unavailable for the 2nd guardian please enter "NA" in all applicable fields.
Mother's/Guardian's Name*

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Father's/Guardian's Name*

First NameLast Name
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number

Emergency Contact Information in Addition to Parents/Guardians
Emergency Contact 1*

First NameLast Name
Relationship to child*
Phone Number*

Area CodePhone Number
Emergency Contact 2*

First NameLast Name
Relationship to child*
Phone Number*

Area CodePhone Number

Physician Information
Primary Care Physician*

First NameLast Name
Phone Number*

Area CodePhone Number
Nephrologist Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Hospital where camper receives treatment/service*

Cook Children'sChildren's Health DallasChildren's Hospital of San AntonioUniversity Children's Health

History of Renal Disease
When was your child first diagnosed?*
Please provide approximate Month and Year
Has your child been in the hospital the past 6 months?*

YesNo
Who is responsible for giving your child's medication at home?*

ChildParentBoth Child and Parent

Transplant/Dialysis
Does your child have a functioning kidney transplant?*

YesNo
If yes, what date was the transplant?
Is your child on dialysis?
Type of access
If Peritoneal Dialysis (PD), which one?

CAPDCCPD
Machine Type (Baxter/Fresinius)
Dialysis Solution used:
Does your child have permission to swim?*

YesNo
If no, why?

Diet
Is your child on a special diet? (Tube feedings, oral supplements, formulas, etc.)*

YesNo
Please bring all supplies necessary to give extra nutritional needs.
Please list diet restrictions
Is your child on tube feedings?

YesNo
Is your child on oral supplements?

YesNo
If yes, please list supplement/formula type:
Is your child on Fluid Restrictions?*

YesNo

Travel Information
Will your child ride the bus BOTH TO AND FROM camp?*

YesNo
If yes, which hospital?

Children's DallasCook Children's Fort WorthSan Antonio
If no, how will your child get to and from camp?

Uploads
Please upload a photo of your child for identification purposes

Browse Files

Cancelof
Please upload your child's up-to-date immunization record

Browse Files

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Please upload your child's COVID-19 vaccine card.

Browse Files

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Please upload a copy of your child's health insurance information (e.g. insurance card, enrollment information, etc.)

Browse Files

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Please upload the Primary Treating Physician Assessment Form.

Browse Files
If you are unable to upload the form at this time, please send the assessment form to campreynal@gmail.com once completed. Link below to print/download form. Cancelof
*Cooks patients* Please disregard completing/uploading the Primary Treating Physician Assessment form. Your assessment forms will be completed and attached separately by your nephrology nurse.
Link to obtain the Primary Treating Physician Assessment Form.

CONDITIONS OF PARTICIPATION

AS THE PARENT OF A CAMP REYNAL PARTICIPANT, I AGREE TO THE FOLLOWING:
1. Camp Reynal accepts no responsibility for the loss, damage or theft of any property.
2. The undersigned understands the importance of and assumes responsibility for notifying Camp Reynal of any changes in the information contained herein, such as work and home phone numbers, work location, emergency contacts, medical information, etc.
3. Should the emergency contact listed on the Camper Application leave his/her place of residence during the camp session, the camp administration will be notified of where he/she can be contacted in case of emergency.
4. All information regarding campers, counselors and staff is highly confidential.
5. I, THE UNDERSIGNED, HAVE REPRESENTED AND DO REPRESENT THAT I HEREBY AGREE TO HOLD HARMLESS, CHILDREN’S MEDICAL CENTER OF DALLAS, COOK CHILDREN’S MEDICAL CENTER, DRISCOLL CHILDREN’S HOSPITAL AND CHRISTUS SANTA ROSA CHILDREN’S HOSPITAL, THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER, NATIONAL KIDNEY FOUNDATION SERVING TEXAS, CAMP REYNAL, AND CAMP JOHN MARC, AND THEIR OFFICERS, DIRECTORS, AGENTS, CONTRACTORS, VOLUNTEERS OR EMPLOYEES FOR ANY AND ALL LIABILITY OF ANY NATURE (I) OCCURRING WHILE MY CHILD IS ATTENDING CAMP REYNAL AND/OR GROWING OUT OR RESULTING FROM ANY INJURY TO, SICKNESS OF, AND/OR DAMAGE TO MY CHILD OR THE UNDERSIGNED RELATING IN ANY WAY TO THE PRESENCE AT, OR USE OF FACILITIES, OR PARTICIPATION IN THE ACTIVITIES OF, CAMP REYNAL, NATIONAL KIDNEY FOUNDATION, AND CAMP JOHN MARC, OR (II) CAUSED, IN WHOLE OR IN PART, BY ANY ACT OR OMISSION OF SAID ORGANIZATIONS, OR THE AGENTS, CONTRACTORS, OR EMPLOYEES OF ANY OF THESE ORGANIZATIONS. I FURTHER RELEASE AND WAIVE ANY AND ALL CLAIMS FOR DAMAGES THAT WE MAY HAVE OR MAY HEREAFTER ACQUIRE DUE TO THE USE OF THE FACILITIES OF CAMP REYNAL, NATIONAL KIDNEY FOUNDATION SERVING TEXAS, AND CAMP JOHN MARC. THE FOREGOING PROVISION APPLIES TO ALL ACTIVITIES CONNECTED WITH CAMP REYNAL INCLUDING, BUT NOT LIMITED TO, ACTIVITIES ON THE CAMPGROUND PROPERTY AND THE PONY FARM, CANOEING, AND ANY AND ALL OTHER OFF-CAMPGROUND ACTIVITIES PLANNED IN ACCORDANCE WITH MY CHILD’S ATTENDANCE AT CAMP REYNAL.
6. I (we) am the parent or legal guardian of a child who is planning to attend Camp Reynal (the “Camp”)through the auspices of the National Kidney Foundation during the 2023 year. In connection with the services to be provided by Camp John Marc and the National Kidney Foundation, I (we) agree to release Camp John Marc and the National Kidney Foundation and their officers, directors, employees, servants, agents and assigns from any and all claims for personal injury, property damage or any other nature which might arise from any and all claims from my (our) use or my (our) child’s use of the Camp. I (we) further agree to refrain from instituting, pursuing or aiding any claim, demand or cause of action against any of the aforementioned entities growing out of, or hereinafter to grow out of my (our) use or my (our) child’s use of the Camp.
7. The undersigned acknowledges and agrees that admission to Camp Reynal as a camper is a privilege that carries with it many responsibilities. Camp Reynal expects campers to participate, to the extent possible, in the activities of the camp and to co-exist in a cooperative spirit. Campers found with alcohol, illegal drugs, or weapons will be immediately dismissed. In addition, should a behavior or discipline problem affect the camp operations or other campers’ enjoyment of Camp Reynal, the undersigned acknowledges Camp Reynal’s right to dismiss those campers responsible for such disruption.
8. The undersigned acknowledges and agrees that attendance at Camp Reynal represents your understanding and acceptance of the rules and responsibilities set forth herein.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature of Parent/Guardian*

Clear
Parent/Guardian Name*

First NameLast Name
Camper Name*

First NameLast Name
Today's Date*

MonthDayYear
Date

ACKNOWLEDGEMENT OF BEHAVIOR POLICY

Policy Objectives:

Management of camper behavior problems at Camp Reynal.
1. Provide a quality experience for all campers and volunteers.
2. Decrease the risk of injury to campers and staff.
3. Outline steps for management of extreme behavior problems.
Implementation:

The staff may identify problem behavior as conduct that is disruptive to others at camp or appears harmful to other campers. The following lists specific examples of those behaviors, followed by intervention the staff may take to provide a solution to the problem in order to reach the given objectives.

Examples of Minor Problems:

Teasing, calling names, talking back to staff, failure to cooperate, speaking out of turn, interrupting.

Examples of Major Problems:

Kicking, hitting, biting, throwing things, spitting, taking other camper’s belongings, pushing, dunking in the pool, etc.

Strike I: Intervening Staff: Cabin Counselors
Course of Action: Call the behavior to the camper’s attention. Inform the camper of the consequences, if the behavior continues (i.e., time out). Redirect the camper’s attention.

Strike II: Intervening Staff: Counselor, Child Life Specialist, Camp Director, Counselor Coordinator
Course of Action: Possible sit-out. Staff explains to the camper that because s/he has continued the behavior, s/he will sit out of the group for several minutes or the reminder of the activity. A call will be made to the child’s parent or legal guardian. Parent/Guardian will be asked for assistance in redirecting child’s undesirable behavior.

Strike III: Intervening Staff: Child Life Specialist, Counselor Coordinator, Camp Director, Camp Reynal Program Director
Course of Action: Child will be sent home. A child is given two opportunities for behavior modification. If the inappropriate behavior is repeated after the call home, the parent or legal guardian will be called to have the child picked up.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Camper Signature*

Clear
Camper Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Parent Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

PERMISSION TO PARTICIPATE IN CAMP ACTIVITIES

I hereby give permission for my child to attend Camp Reynal from May 28, 2023 to June 2, 2023. I understand that attending Camp Reynal includes sleeping, eating, engaging in activities, and receiving dialysis treatment, if applicable. I understand that my child may take part in certain physical activities offered by Camp Reynal, including: wilderness programs, fishing, sports and games, horseback riding, swimming and other water activities, and the ropes course.
Please choose an option*

I authorize my child to participate in all Camp Reynal activitiesI do not authorize my child to participate in all Camp Reynal activities (please list)
I do not authorize my child to participate in: (list activities)

AUTHORIZATION TO PROVIDE MEDICAL TREATMENT

I authorize the Camp Reynal medical staff to provide:
(Check one)*

HemodialysisPeritoneal Dialysis
to my child while he/she is at Camp Reynal. I understand that an attending physician and dialysis personnel will be assigned to my child.

I understand that the attending physician assigned to my child will determine the times and prescription for my child’s dialysis or other Medical Treatment and my child’s medication and dialysis treatment may be changed during his/her week at Camp Reynal. I hereby authorize the attending physician and dialysis personnel to change my child’s medication and dialysis treatment, if it is considered to be appropriate.

I AM AWARE THAT HEMODIALYSIS/PERITONEAL DIALYSIS, LIKE MANY TREATMENTS IN MEDICINE, IS NOT PERFECT AND DOES NOT FULLY REPLACE ALL FUNCTIONS OF A NORMAL KIDNEY. I UNDERSTAND THAT CERTAIN KNOWN AND UNKNOWN RISKS AND ADVERSE SIDE EFFECTS ARE ASSOCIATED WITH THE USE OF HEMODIALYSIS/PERITONEAL DIALYSIS. I ASSUME ALL RISKS IN CONNECTION THERETO, AND I RELEASE AND AGREE TO DEFEND AND HOLD HARMLESS CAMP REYNAL AND NATIONAL KIDNEY FOUNDATION, AND THEIR OFFICERS, DIRECTORS, AGENTS, CONTRACTORS, VOLUNTEERS AND EMPLOYEES, FROM ALL LIABILITY, CLAIMS AND CAUSES OF WHATSOEVER NATURE, WHICH MAY ARISE OUT OF, OR RESULT FROM, THIS TREATMENT OR PROCEDURE.

CONSENT FOR EMERGENCY MEDICAL TREATMENT

In case my child needs emergency medical or surgical care and treatment during his/her stay at Camp Reynal, I consent for Camp Reynal to render or arrange for any x-rays, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care that Camp Reynal deems necessary. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE TO PAY FOR ANY AND ALL EMERGENCY MEDICAL ATTENTION REQUIRED BY MY CHILD, WHICH EXCEEDS THE MEDICAL TREATMENT AUTHORIZED ABOVE. I ALSO AGREE TO INDEMNIFY AND HOLD CAMP REYNAL AND NATIONAL KIDNEY FOUNDATION AND THEIR OFFICERS, DIRECTORS, AGENTS, VOLUNTEERS, CONTRACTORS AND EMPLOYEES HARMLESS FROM ANY AND ALL CLAIMS, DAMAGES, LIABILITIES, JUDGMENTS, INCLUDING REASONABLE ATTORNEY’S FEES, ARISING FROM EMERGENCY MEDICAL TREATMENT SOUGHT AND PROVIDED TO MY CHILD.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

PERMISSION TO APPLY SUNSCREEN
Please choose an option:*

I authorize any staff at Camp Reynal to apply sunscreen to my child, for protection from the sun when needed.I DO NOT authorize any staff at Camp Reynal to apply sunscreen to my child, for protection from the sun when needed.
Camper Name*

First NameLast Name
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

PERMISSION FOR USE OF PHOTOGRAPH

I hereby voluntarily authorize the use or disclosure of my child’s name and photographic images in hard copy and electronic format (“Photographs”) as described in this authorization form (this “Authorization) from Camp Reynal, National Kidney Foundation and any of its authorized agents and/or any other personal representatives to the general public (the “Public”).

Camper’s Name: {camperName} (the “Camper”)

The Photographs may be used or disclosed to the Public in brochures, newsletters, informational materials, news stories, media releases, print media and other materials in any format for the purposes of marketing, fundraising and general publicity on behalf of Camp Reynal and National Kidney Foundation.

I understand that I may refuse to sign this Authorization, and that my child’s health care treatment and attendance at Camp Reynal will not be conditioned upon signing this form. I understand that my child’s Photographs may not be protected by federal privacy regulations. I also understand that I may revoke this Authorization at any time by notifying Camp Reynal and the National Kidney Foundation in writing, but such revocation will not have effect on any actions Camp Reynal took before the receipt of the revocation of this Authorization. I understand that I may see the Photographs described in this Authorization, if I request to do so in writing.
Please choose an option:*

I hereby voluntarily authorize the use or disclosure of my child’s name and photographic images in hard copy and electronic format (“Photographs”) as described in this authorization form (this “Authorization) from Camp Reynal, National Kidney Foundation and any of its authorized agents and/or any other personal representatives to the general public (the “Public”).I DO NOT authorize the use or disclosure of my child’s name and photographic images in hard copy and electronic format (“Photographs”) as described in this authorization form (this “Authorization) from Camp Reynal, National Kidney Foundation and any of its authorized agents and/or any other personal representatives to the general public (the “Public”).
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Relationship to camper:*
Mother, Father, Guardian, etc.
Date*

MonthDayYear
Date

PERMISSION TO CONTACT CAMPER

I hereby give permission for representatives of Camp Reynal and the National Kidney Foundation to contact me, on behalf of my child, by mail, e-mail or telephone in order to provide me and my child with information regarding activities, services, and programs of any type that involved Camp Reynal and/or the National Kidney Foundation.

Camper Name: {camperName} (the "Camper")
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Relationship to camper:*
Mother, Father, Guardian, etc.

Camper Pick-Up Authorization Form

In an effort to protect our campers, we are asking that you let us know, in advance, who has your permission, other than you, to pick up your child. You may pre-authorize individuals by listing them below. Please let these individuals know that they may be asked to show photo identification. Anyone coming to pick up your child who is not on the list will not be allowed to leave with your child unless we have received a prior, written notification from the custodial parents/guardians.
Choose an option:*

Only custodial parents/guardians are authorized to pick up your child.The following individuals are authorized to pick up your child: (fields will populate below)
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Camper
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Camper
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Camper
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to Camper
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature

Clear
Parent/Guardian Name

First NameLast Name
Date

MonthDayYear
Date

General Health Policy
NKF Camp Reynal Policy

To reduce the risk of serious illness at camp, please do not plan to send your camper to camp if they have had any of the following flu-like symptoms in the 14 days prior to the start of camp:
- Fever over 100˚F
- Sore Throat
- Runny/Stuffy nose along with cough or sore throat
If your child develops any flu-like symptoms while at camp, he/she will be isolated in a protected area in the medical building and you will be contacted and asked to pick them up from camp.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

NKF Liability Waiver

By attending or organizing this event and signing this form, I expressly warrant that:
- I will indemnify and hold the National Kidney Foundation (NKF) harmless from any and all claims of any kind or nature whatsoever arising out of, or in any way related to, this fundraising initiative.
- I acknowledge an inherent risk of exposure to COVID-19 exists in any public place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Centers for Disease Control and Prevention, people with underlying medical conditions and older adults are especially vulnerable.
- I will indemnify and hold the NKF harmless from any and all claims of any kind or nature whatsoever arising out of, or in any way related to an alleged exposure to, or contracting of, COVID-19 by any attendee who alleges such exposure or illness during or after the Event.
- I voluntarily assume all risks related to exposure to COVID-19.
In consideration for being permitted to organize or participate in this event, I, the undersigned, waive and release NKF and its directors, officers, administrators, representatives and executors, employees, volunteers, agents, supervisors (collectively, the “Releasees”), from any and all claims, liabilities, or causes of action arising out of an injury to me, loss articles, loss of articles in car, car damage and car theft and from any and all claims, liabilities, or causes of action arising from my participation or attendance in this event. I voluntarily agree for myself, my family, heirs, assignees the following:
1. To assume full responsibility for any risks of loss, or personal injury, including death that may be sustained by me, or any loss or damage to property owned by me, as a result of participating in the event, including getting sick with COVID‐19 or any other communicable diseases.
2. To release, waive, hold harmless, discharge, and covenant not to sue the Releasees from any and all liability, claims, actions, demands, expenses, attorney fees, breach of contract actions, breach of statutory duty or other duty of care, warranty, strict liability actions, and causes of action whatsoever, that I might have or may acquire in the future, arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in the Event including, but not limited to, any claim that the act or omission complained of was in whole or in part by the negligence or carelessness of the Releasees.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

Camp John Marc Summer/Weekend Camper (Non-Family Camps)

Release and Indemnity Agreement

Please read this Release and Indemnity Agreement (“Release”) carefully before signing.

Name of Camper:{camperName} (hereinafter “Camper”)

Name of Parent or guardian: ______________________________________(hereinafter “Parent”)

A. PARTICIPATION CONSENT: For myself and Camper, the undersigned understands and acknowledges that risks and dangers exist during the camp program(s) that Camper has applied to attend and that occasionally accidents occur during camp or retreat activities and that Camper may sustain serious personal injury and property damages because of such activities. These activities include but are not limited to the potential hazards of boating, swimming, horseback riding, archery, sports, ropes or challenge course exercises, climbing structures, hiking, camping, cooking, and potential hazards of the presence of wildlife, depending on other people, accident or illness, the forces of nature, extreme temperature, inclement weather and travel by air, train, boat, automobile or other conveyance. For myself and Camper, I understand and agree that Camper will be in an environment that involves elements related to nature, camping or community living such as insects and insect bites, sun exposure, or communicable illness, including Covid-19. For myself and Camper, I understand that CJM does not have any medical staff on-site, although the user group will have some medical staff, the closest emergency room is approximately twenty (20) miles from CJM, and emergency services for the area where CJM is located are volunteer Bosque County EMS. Knowing the risks of camp and retreat activities, nevertheless, for myself and Camper, I agree to assume those risks. For myself and Camper, Camper and I are not under and will not be under the influence of any chemical substance (except prescription medicine taken as prescribed), including alcohol, while at CJM and while traveling to or from CJM. For myself and Camper, I understand that participation in this program is entirely voluntary and that Camper may elect to participate, decline to participate, or limit or discontinue participation at any time. For myself and Camper, I have applied for this program and accept full responsibility for my decision for Camper to participate or not to participate and agree to follow all safety instructions.

B. MEDIA RELEASE: For myself and Camper, I understand that this media release is granted for the use and benefit of CJM and the user group sponsoring any specific camp session. For myself and Camper, I give permission and consent for CJM and the user group to interview and/or take photographs, audio or audio visual recordings of Parent and Camper and grant CJM and the user group permission to use Camper’s and my likeness or voice in television, film, video, print or other media used to promote or publicize CJM, or the camp session(s) Camper attends; provided these materials are distributed without a specific charge to the recipient except for the cost of precuring any mass media materials in which they are incorporated. For myself and Camper, I acknowledge that CJM shall have all rights of copyright in and to such photographs, videos, audio, and images and may use such copyright fully. For myself and Camper, I also hereby release Camp John Marc, and Camp John Marc Foundation, Inc. and the user group(s) and their employees, agents, and directors, for liability connected with the taking of and use of these materials. In addition, for myself and Camper, I waive all rights, interest or claims for payment in connection with any exhibition or release of these materials. This consent is voluntary, and I give it in the interest of public information, education, the furtherance of the goals of CJM or the user group, or other lawful purposes.

C. RELEASE: For and in consideration of the right to participate in CJM, and a camp program sponsored by the user group(s) of the camp session Camper attends, for myself and Camper, I completely release, acquit, and forever discharge Camp John Marc, Camp John Marc Foundation, Inc. the user group(s) sponsoring the camp session Camper attends, and their respective counselors, employees, volunteers, directors, officers, agents, affiliates, partners, members, shareholders and/or associates (hereinafter collectively referred to as the “Released Parties”) of and from any and all claims, demands, causes of action, obligations, liens, damages, losses, costs, attorneys’ fees and expense of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, which I and/ or Camper now have or which may arise from or in connection with Camper’s participation in any activities arranged for Camper by CJM, the user group(s) sponsoring the camp session, and/or the Released Parties. It is my express intention that this Release is a full release of the Released Parties for the consequences of the Released Parties’ own actual or alleged negligence, gross negligence, strict or absolute liability, or other fault. I agree to pay attorneys’ fees and court costs of the Released Parties and myself associated with claims and/or litigation brought by or on behalf of the undersigned or on behalf Camper, the estate of Camper, or the wrongful death beneficiaries of Camper and/or me against CJM, the user group(s) or the Released Parties.

D. INDEMNITY: It is further expressly agreed and understood that the undersigned will defend, indemnify, and hold harmless the Released Parties from any liability, judgment or claim asserted by, through or on behalf of the undersigned and/ or Camper, the estate of Camper, or the wrongful death beneficiaries of Camper arising out or in any way pertaining to the participation in CJM, and/ or a camp program sponsored by the user group(s) of the camp session(s) Camper attends. The foregoing obligations to defend, indemnify and hold harmless shall be enforceable without regard to the actual or alleged negligence, gross negligence, strict or absolutely liability or other fault of the Released Parties, it being the express intention of the undersigned to indemnify the Released Parties for the consequences of the Released Parties’ own actual or alleged negligence, gross negligence, strict or absolute liability or other fault.

I attest that I am the Parent and/ or legal guardian of the minor Camper identified above, or if Camper is 18 years or older, Camper shall also sign.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date

Camper Name*

First NameLast Name
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Signature*

Clear
Parent/Guardian Name*

First NameLast Name
Date*

MonthDayYear
Date
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Camp Reynal 2023

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