Release Consent Form      
         
YMCA STORER CAMPS      
         
Michigan Youth Camp Safety Laws require licensed camps to get authorization from parent/guardians for the release of their child to specific individuals. Please indicate below the individuals to whom your son or daughter may be released.
         
Persons authorized to pick up your child must be listed below with name and contact information regardless of their relationship to the child. For example, if you, the parent will be picking up your child, please list your name immediately below. Also list additional relatives, friends, etc., who might be picking up your child in your absence.
Fields in pink are required    
Name of Camper:    
Program Name: Session Number:
Your Email:    
1. Person Authorized to Pick-Up Your Child    
Name: Relationship to Camper:
Cell Phone: Home Phone: Work Phone:
 
2. Person Authorized to Pick-Up Your Child
Name: Relationship to Camper:
Cell Phone: Home Phone: Work Phone:
 
3. Person Authorized to Pick-Up Your Child
Name: Relationship to Camper:
Cell Phone: Home Phone: Work Phone:
         
You may make changes to this form at any time prior to pick up. ALL changes must be made in
writing by the parents/guardians and submitted to the camp office.
         
If parent(s) or guardian(s) are NOT listed above, please complete the information below:
Name: Relationship:
Cell Phone: Home Phone: Work Phone:

ATTENTION – PLEASE READ THE FOLLOWING CAREFULLY. THIS WAIVER AFFECTS YOUR LEGAL RIGHTS.

I UNDERSTAND THAT CLICKING THIS BOX IS THE EQUIVALENT OF MY SIGNATURE AND DEMONSTRATES ACCEPTANCE OF THE ABOVE TERMS IN THEIR ENTIRETY.