The information contained in this form is correct, as far as I know, and the child herein described has permission to engage in all camp activities except as
noted. I understand that health/accident insurance coverage is the responsibility of the parent/guardian. I hereby give permission to YMCA Storer Camps to
secure emergency medical, routine medical, surgical treatment, and non-surgical care for the child named on this form, while at camp. I also understand that
the parent/guardian is fully responsible for the camper’s transportation if he/she is dismissed for disciplinary, behavior or medical reasons. I absolve the YMCA
of Greater Toledo/Storer Camps and all of its employees of any and all liability, financial and/or otherwise arising from administration of medication to my child
under the terms of this release. YMCA Storer Camps is not responsible for payment of any medical expenses incurred during participation at camp.
In consideration for being allowed to participate in the YMCA’s programs, I agree to assume the risk of such activities and programs, and I further
agree to hold harmless the YMCA of Greater Toledo, it’s officers, employees and representatives from any and all claims, suits, losses, or related causes
of action for damages, including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way
from the activities. I grant permission for me or my child to participate in all planned camp activities including out of camp trips by van or bus, hiking
or horseback riding. The YMCA is not responsible for lost, stolen or damaged personal articles. I also authorize the YMCA to have and use
photographs, slides or video tapes of me, my child, or my family as may be needed for its public relations programs. I acknowledge that this General
Release of Liability and Authorization for Treatment of the YMCA is binding on me personally and on my heirs, personal representatives, successors and
Limited Purpose Power of Attorney: Consent to Treatment of Minor (Must be signed by parent or legal guardian)
By digital signature(s) below, the undersigned appoints YMCA Storer Camps, to act alone, or delegate to another person, the power to consent on our behalf to all
emergency treatment and/or medical care (except elective surgery) of (child’s name)
determined to be necessary or desirable by
our child’s attending physician at the hospital. This Power of Attorney shall continue through the participant’s stay at camp, or until revoked by the
undersigned, whichever is earlier. Physicians or the hospital’s medical staff may assume and rely on this authorization being current and in effect during such
period unless notified otherwise.
The undersigned certify that they read this Power of Attorney (or had it read to them), that they understand this Power of Attorney, and sign it voluntarily.
This agreement will be enforced in accordance with the law of the State of Michigan.
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.
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