2011 Camp Forget-Me-Not / Camp Erin DC

The following questions are NOT used to determine acceptance. This information is used to better understand and better meet the needs of the communities we serve. Your personal information is kept confidential.

Communication Release

I give permission to have information released in my child’s records and verbal information related to my child’s treatment, as appropriate. I have discussed the nature of the information to be released and the purpose for its release with Camp Forget-Me-Not/Camp Erin DC staff. This consent will be in effect for the duration of the child’s participation in Camp Forget-Me-Not/Camp Erin DC.

Authorization for Emergency Medical Treatment

Should a medical emergency arise during the above-named child’s participation in a Camp Forget-Me-Not/Camp Erin DC activity, I understand that reasonable efforts will be made to contact me or my designated alternate Emergency Contact at the phone numbers provided in this application. As the parent/guardian, I consent for the child described herein to receive medical treatment deemed necessary under the circumstances by camp medical staff and/or 911, and to assume the liability for any medical expenses involved. If my child’s life or health may be adversely affected by a delay in attempting to contact me or my designated emergency contact, I consent to the immediate administration of life-saving measures deemed necessary under the circumstances. This authorization extends to the child’s participation in any activity sponsored by Camp Forget-Me-Not/Camp Erin DC.

Permission to Dispense Over-The-Counter (OTC) Medications

I give consent to the medical staff of Camp Forget-Me-Not/Camp Erin DC to use his/her/their professional medical judgment in determining if my child is in need of an Over-The-Counter medicine. I hereby give permission to the camp medical staff to dispense appropriately and as needed: Tylenol, Motrin and/or Benadryl or their generic equivalents: acetaminophen, ibuprofen, diphenhydramine.

Parent/Guardian Permission Statement

I certify that I am the parent/legal guardian of the above named child. The information provided in this application is complete and correct to the best of my knowledge. The child described herein has my permission to engage in all prescribed camp activities, except as noted. If she/he/they appears to be ill, I will not send her/him/them to Camp. I hereby grant permission to the Camp Forget-Me-Not/Camp Erin DC staff to share information contained in this application with the volunteer(s) working with the child.

Liability Release

I understand and agree that Camp Forget-Me-Not/Camp Erin DC, Wendt Center for Loss and Healing, its Board of Directors, Officers, Employees, and Volunteers are released from any legal responsibility and/or liability arising out of any accidents or illnesses which occur during the child’s participation in Camp Forget-Me-Not/Camp Erin DC.

Publicity Permission

Videotaping and/or photography may occur during Camp activities. I understand that such material may be used in future publicity and/or educational efforts by the Wendt Center for Loss and Healing/Camp Forget-Me-Not/Camp Erin DC. In addition, with staff permission and supervision, news media may photograph, videotape, and/or interview some of the children attending Camp. I consent to having the camper’s voice and/or image recorded or photographed for use as outlined above.

Art Release

I give my consent that all art (visual, written, and performance) produced at Camp Forget-Me-Not/Camp Erin DC can be used and/or photographed for documentation of therapeutic art programs, education of graduate student interns; research, presentations, and/or publication; exhibit or display. I understand that my child’s confidentiality will be protected at all times and that their name and other identifying data will be altered to preserve my child’s identity.