4 places to sign or initial
REPRESENTATION AND EMERGENCY AUTHORIZATION
This health information is correct so far as I know, and the person herein described has
permission to engage in all prescribed camp activities except as noted. I hereby give
permission to the medical personnel selected by The School of Environmental
Education/Camp Kappe, or its authorized agent to order x-ray, routine test and treatment
for me/or my child in the event I cannot be reached in an emergency. I hereby give
permission to the physician selected by The School of Environmental Education/Camp
Kappe to order injection and/or anesthesia and/or surgery for me/or my child as named
above. Such authorization for emergency treatment shall also include, but not be limited
to, charges incurred for the providing of aid and arranging evacuation if The School of
Environmental Education/Camp Kappe or its agents determine that such evacuation is
necessary or desirable. I further agree to assume responsibility for the cost of any medical
care and acknowledge that these costs are the financial responsibility of the undersigned.
I also understand and agree to abide with the restrictions placed on my camp activity and
rules set forth by The School of Environmental Education/Camp Kappe.
Signature of parent or Guardian
_______________________________________ Date__________________________
I understand that students will reside in cabins with other students attending S.E.E. and
that every effortwill be made to have one adult chaperone per seven students and at least
two adult chaperones in eachcabin. I expect all attending adults to have criminal
background checks and be “Virtus” trained.
_________
Initial
I also understand that there will be no refund if my child is sent home due to misbehaving.
________
Initial
PARENTS’ PERMISSION FOR THE PUBLICATION OF STUDENT
WORK/PICTURES
I understand that from time-to-time the school may wish to publish examples of student
projects,
photographs of students, and other work on an internet accessible World Wide Web
server
______My child’s work can be published on the internet and photographs of my child
can be published.
______I would prefer that my child’s work and picture not be published on the internet.
Parent Name
(print):___________________________________________________________
Parent Signature:____________________________________Date:________________
Student Name
(print):_______________________________________________________
Student Signature:_________________________________________________________