Our members make a difference in the world around us. You can help give back to your community simply by getting involved.
Please list ALL medications (including over the counter or non-prescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration.
Check "Yes" or "No" for each statement. Please explain “Yes” answers. The camp may contact you for additional information.
Health-Care Providers
I am the Parent/Guardian of the above-named Participant who is under eighteen years of age and am fully competent to sign this Agreement.
I realize that my childʼs participation in camp activities carries with it risk of injury/illness, even when all rules are followed and conditions are optimal. There are various safety problems that can increase injury risk potential. Some safety problems are regularly identified and addressed (i.e., heat illness and the administration of liquids frequently; the use of high quality, durable, and safe protective equipment). Some safety problems may be less clearly identified (i.e., mechanisms of head and neck injuries or ankle and knee injuries, etc.) and, therefore, prevention and protection are difficult. Risk can be increased due to the participantʼs lack of compliance with specified instructions (i.e., knowingly using dangerous or faulty equipment, participating in activities when environmental conditions are dangerous (high heat/high humidity, lightning). Even in the best facilities, with adequate supervision, use of all protective equipment, and compliance with all of the rules, there remains an inherent risk of injury/illness in any camp activity.
I acknowledge that my childʼs voluntary participation in this camp may expose him/her to hazards or risks that may result in his/her illness, personal injury, or death. I acknowledge that I am aware of the risks of injury/illness and knowledgeable concerning rules, equipment and practices being employed by KJZT Family Life camp personnel to minimize my childʼs risk of sustaining an injury/illness while participating in camp activities. My child agrees to use all required protective equipment and follow all rules and instructions from KJZT Family Life camp counselors regarding safety. Also, my child has no known physical infirmities which could be worsened or aggravated by participation and I declare him/her physically fit and in good medical condition to engage in all camp activities.
In consideration of my child being permitted to participate in the camp and to use the programʼs facilities and equipment, I hereby accept all risk to my childʼs health and of his/her injury or death that may result from such participation. I hereby release KJZT Family Life, its affiliates, governing board, officers, employees, and representatives from any and all liability in any way resulting or arising from any injuries (including death), damage, loss or costs that may incur as a result of my childʼs participation in the camp. I intend this release to be binding upon my heirs, executors, administrators and assigns. I further agree to indemnify, defend and hold harmless KJZT and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from Participant's negligent or intentional act or omission while participating in the described Activity.
I have carefully read this agreement and I understand that it is a legally binding document that affects my childʼs legal rights and remedies.
Your browser does not support e-Signature field.
Parent/Guardian Authorizations: This health history is correct and accurately reflects the health status of the camper to whom it pertains, and the person herein described has permission to engage in all camp activities (boating, canoeing, swimming, high ropes etc.) except as noted on this formsʼs reverse side.
I, the undersigned, as the parent or legal guardian of {name-1-first-name} {name-1-last-name} (a minor) hereby authorize such diagnostic, medical and/or surgical treatment of such minor as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury of the minor. The attending provider, appropriate staff, and KJZT Family Life and its governing board, officers, regents, and representatives shall not be responsible in any way for any consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims and causes of action that may arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care and to the best of their ability.
I agree to furnish my child with transportation to and from the campsite. I have read the camp rules and regulation and agree to cooperate with the camp management. I understand that reasonable precautions are taken for the health and safety of all campers. I will not hold the KJZT Family Life or any staff members responsible in case of accident. I agree that I am responsible for any damages caused by my child during his/her camping period. I agree that the KJZT Family Life accepts absolutely no responsibility for any loss or damage to any camperʼs property incurred during the camping session or while in transit.
I hereby give my permission for my child to leave the camp grounds to participate in camp programs. The KJZT Family Life reserves the right to request that a parent or guardian remove a camper from the camp in the event that he/she causes problems affecting the experiences of the other campers, chaperones, or camp staff. This will be done at the sole discretion of the camp director.
4604 East Ben White Blvd | Austin, TX 78744
Phone: 1.888.253.2338 | 1.512.444.9586
Email: info@kjzt.com
