Informed Consent and Release Agreement
I understand that participation in outdoor activities at McKenna Ranch involves a certain degree of risk and can be physically, mentally, and emotionally demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct.
In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp medical staff, camp management, and/or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. §§160.103, 164.501, etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.
I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve the sharing of the information on this form with McKenna Ranch volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of all activities at McKenna Ranch.
I release the McKenna Ranch, its owner Kathryn McKenna Mueller, as well as McKenna Ranch staff, employees, volunteers, related parties, or other adults associated with the activity, from any and all claims or liability arising out of this participation.
Yes, I agree to these terms
No, I do not agree to these terms
I hereby assign and grant to the McKenna Ranch the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child at all camp activities, and I hereby release the McKenna Ranch and the McKenna Ranch staff, employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication. I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the McKenna Ranch, and I specifically waive any right to any compensation I may have for any of the foregoing.
"By typing my name and the name(s) of the minor(s) who will be participating in activities at McKenna Ranch, I acknowledge that I have read, accepted, and understand the McKenna Ranch Camp's Informed Consent and Release Agreement."
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