CAMPER NAME(S):
HAVERIM PARENT PERMISSION FORM
Health Insurance Information
Insurance Company
Group #
Primary Subscriber
Policy #
**1 FORM PER FAMILY**
Permission to Treat:
I understand that Camp Haverim will contact me regarding any emergency pertaining to my camper(s). If I cannot be
reached, Camp Haverim and the Merage JCC has my permission to seek medical attention for my camper(s) at the
nearest facility. I agree to assume all expenses for transportation and medical treatment. I consent to any treatment,
surgery, diagnostic procedures or the administration of anesthesia which may be carried out based on the medical
judgment of the attending physician. During an emergency situation, Camp Haverim and the Merage JCC has my
permission to obtain a copy of my camper’s health records from providers who treat my camper(s) and these
providers may talk with designated Camp Haverim and/or Merage JCC staff in order to provide information pertaining
to the issue(s) at hand.
Field Trip Permission:
I give permission for my camper(s) to attend activities which are held off campus grounds in designated vehicles (i.e.
Field Trips) as applicable to my camper’s specific enrollment. I understand that Camp Haverim will provide adult
supervision on all trips and will make every effort to ensure the safety of all participants. I am also aware that the
Camp Haverim and the Merage JCC cannot assume responsibility for any accident or illness going to, from, or during
the trip.
Release of Liability:
I release Camp Haverim and the Merage JCC and its agents, servants and employees from any liability for any injury
or illness to my camper(s) while at camp.
Camper Insurance:
I understand that the Merage JCC does not offer medical insurance relating to accidents and/or injuries that may
result from my camper’s participation in Camp Haverim. I will be responsible for maintaining appropriate medical
insurance for my camper(s).
Medication Protocol:
I give my consent for specific approved medications and first aid supplies for use by my camper(s) as needed during
camp-related activities. I understand these medications and supplies are available for use by designated camp staff
as outlined in the Protocol Medication Policy found in the Parent Handbook. I realize a physician will not be present
during the administration of medication and that medication may be administered by a non-medical person. Further, I
indemnify and hold harmless the Merage JCC and Camp Haverim employees from and against all claims arising out
of the Protocol Medication Policy and administration of medication under this policy.
Activity Permission:
My camper(s) has (have) my permission and is (are) able to participate in all camp related activities expect where
previously noted.
Pre Care, Post Care and Lunch Charges Permission:
I give permission for Camp Haverim to charge my card on file for any extended care or lunch charges (as applicable)
that I did not pre-register for. I am aware that the drop-in charge for Pre Care is $10/day per camper and for Post
Care is $12/day per camper. I am also aware that the cost for a camp lunch is $6.50/lunch.
Parent Manual Acknowledgment and Receipt:
I have read the Camp Haverim Parent Manual (found online or requested from the camp office) and understand all
camp policies and procedures provided. I agree to abide by all conditions set forth within the manual.
Parent/Guardian Signature (Certified Electronic OK)
Date