Student age

If you are an adult leader registering just write in (Leader)

Email

Has your student attended camp with us before?

Relationship to Student:

Physician/Medical Clinic

Name of Medical Insurance

Medical Insurance Policy Number

Medical Conditions

Please list any medical conditions or allergies we should be aware of for the person attending this event.

List any medications

Please write out any medications your student will be bringing to the camp. For all students bringing medications, there will also be a secondary form which will have to be filled out at the time the student is dropped off at the camp. This form will need to be submitted, along with the medications, to the administrator and medical care person at the time of camp check in, July 20th.

MEDICAL CONSENT, RELEASE OF LIABILITY, AND PHOTO RELEASE Medical Consent I (parent/guardian if under age 18)_________________________________, authorize the adult sponsor of Outliers Community, Arroyo Grande, CA, to consent to any X-ray, examination, anesthetic, medical or surgical supervision and on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful. This authorization given pursuant to Section 25.8 of the Civil Code of California, and shall remain effective through 7/23/2023. Liability release I hereby assume risk of, responsibility and liability for, and release, forever discharge and agree to hold harmless Outliers Community, Arroyo Grande, CA its directors, employees, volunteers and event participants, from all liability, claims, demands, expenses, costs and obligations directly or indirectly resulting from personal injury, sickness, death and or property damage associated with any activity covered by this form. The undersigned further agrees to hold harmless, defend and indemnify Outliers Community, its directors, employees, volunteers and event participants for all liability, claims, demands, expenses, costs and obligations directly or indirectly caused by my negligent, willful or intentional act. Photo Release I authorize Outliers Community at its sole discretion, to use and publish for any lawful purpose and without compensation, photographs, video, audio and or other depictions of my child at this event. This authorization shall remain in effect until revoked in writing.

Parent/Guardian signature:

Are you a part of a local church or youth ministry? If so which one?

Reserve Your Spot at Camp!

Subscribe to our Newsletter