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Family Waiver of Liability and Release and Medical Information Form

This form may also be downloaded HERE

  • Children's Name and Ages

  • General Waiver:

    The undersigned recognize that there are inherent risks involved in sports, camping and fitness activities. In consideration of the services provided, I on behalf of myself and my children named above, hereby release and hold harmless, ACA-Camp Geneva, the owner of the property upon which said activity is conducted, and their directors, trustees, officers, employees, agents and volunteers from any and all liability for injuries, including those resulting in death, and/or illnesses incurred while participating or attending any event or in any facility of the the Camp.

    By signing this document, the participant, parent or legal guardian confirms that he or she has authority to sign, has read the entire document and has understanding that the document waives certain rights of the person signing or the participant.

    Medical Information

    Please note that during Family Camping Weekends all children are required to be accompanied by a parent, guardian or another adult who has agreed to be responsible for the child. Parents, guardians and responsible adults will be responsible for the health and safety of the children under their care. The information provided below is given for purposes of medical emergencies when a parent, guardian or responsible adult is not available to provide for medical decisions and care.

  • Allergies

    Do you or any of your children listed above have any of the following allergies? If so, please indicate the name of the parent or children with the allergy
  • Insurance

  • Insurance Claims:

    Medical Treatment Authorization:

    I further understand that, in the event my child requires medical or dental treatment while engaged in activities at the Camp, reasonable efforts will be made to contact a parent or guardian; however, if a parent or guardian cannot be reached, I hereby consent and give permission to the director, trustee, officer, employee, agent or volunteer acting on behalf of Camp Geneva as agent for me, to consent to any X-ray examination, injections, anesthesia, medical, dental or surgical diagnosis and treatment, and hospital care and treatment advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the law of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all of my and my children’s medical allergies, medications being taken, medical problems and other pertinent information. If there are any changes, I will notify the Camp.

    Photo Release:

    The undersigned authorizes Camp Geneva to use and display any photographs or images of me or my child taken while engaged in activities sponsored by the Camp in any publication, multimedia production, display, advertisement or other publication. The undersigned releases and forever discharges Camp Geneva, as well, as their agents, officers, volunteers and employees from any and all claims and demands arising out of or in connection with the use of said photographs / images.

    This FAMILY WAIVER OF LIABILITY AND RELEASE AND MEDICAL INFORMATION FORM is effective throughout the camp session for which I or my child is registered and may not be revoked, altered, amended or avoided at any time.