Release and Agreement

Release and Agreement Form

UCCY/ Camp STORM RELEASE and AGREEMENT FORM

I am the custodial parent or guardian of ___________________________, who is enrolled in Camp STORM located at 4050 Gamble Mill Road, Avera, GA.

By signing this statement, I am acknowledging that this camper is physically and mentally capable of participating in all camp activities.

I understand that participation in Camp STORM involves athletic, recreational, and other activities which by their nature may expose my child / ward to risks of property damage and personal injury, including injury that may be fatal.

Those risks include but are not limited to sickness, broken bones, sprains, concussions and injury from inclement weather. I acknowledge these inherent risks and dangers, and agree to voluntarily assume and be responsible for risks of any injury or damage to person or property.

In consideration of my child / ward’s participation in Camp STORM, the undersigned custodial parent or guardian covenants not to sue and agrees to release, discharge, hold harmless, and indemnify Darlington, its officers, agents, trustees, and affiliates from and against any and all liability, claims, damages, or injury to persons and property, including costs and attorneys’ fees, arising out of or in any way associated with my child / ward’s participation, attendance, travel to and from, or other involvement in Camp STORM, including, but not limited to, all acts or omissions constituting negligence on Camp STORM part, except for willful or wanton negligence or misconduct.

Media Release: I give permission to UCCY/Camp STORM to use and publish my photos, or videos for educational and promotional purposes without compensation.

I agree that this document – and in particular the release, waiver, and indemnity provisions – shall be construed under the laws of the State of Georgia of the United States of America, and that if any portion is held invalid or unenforceable, the remainder shall remain and continue in full force and effect.

_____________________________ _____________________________________________________________________________________

Print Camper Name (Age) Address

_____________________________ _____________________________________________________________________________________

E-mail Address City, State, Zip

_____________________________ _____________________________________________________________________________________

Emergency Contact Name Emergency Contact Number

I hereby give permission for camp staff members, Camp STORM officials, or athletic trainers to obtain any emergency medical treatment while the

camper listed above is on Camp STORM campus.

I hereby accept this agreement and consent and agree to all the above terms and conditions.

_____________________________ _____________________________________________________________________________________

Custodial Parent or Legal Guardian Date

_____________________________ _____________________________________________________________________________________

Medical Insurance Provider Policy Number

Please list any food or medicine allergies or medical issues of which camp directors should be aware.

__________________________________________________________________________________________________________________