Permission and Release Form

- Green Swamp Youth Campers -

PARENTAL/GUARDIAN PERMISSION AND RELEASE OF LIABILITY FORM

This Form Must Be Signed By The Parent/Guardian of Any Participant Under 18 Years Old

PLEASE PRINT NEATLY - THANK YOU!

FIRST NAME:_________________________________LAST NAME: ___________________________________

AGE:______ DATE OF BIRTH:_____/______/______

ADDRESS: __________________________________________________________APT: __________________

CITY:___________________________________________STATE:____________

ZIP:______________________

PHONE: (______)_______- ___________ E-MAIL:_________________________________________________

IN CASE OF EMERGENCY CALL: _____________________________PHONE:(______)_______- ____________

LIST ALL ALLERGIES / MEDICATIONS: _________________________________________________________________________________________

ANY MEDICAL CONDITIONS: _________________________________________________________________________________________

HEALTH INSURANCE PROVIDER:_________________________POLICY #:_______________________________

I hereby grant permission for my child __________________________________________ to participate in any and all activities and/or programs provided by or through Green Swamp Youth Campers These activities and/or programs may include, but are not limited to: camping, canoeing, kayaking, white water rafting, inner tubing, snorkeling, rock climbing, rappelling, caving, backpacking, team building, individual & team sports, individual & group games.

I hereby agree as follows: I fully understand and acknowledge that: (a) risks and dangers exist in my child's participation and equipment use of activities including, but not limited to: camping, canoeing, kayaking, white water rafting, inner tubing, snorkeling, rock climbing, rappelling, caving, backpacking, team building, individual & team sports, individual & group games; (b) my child's participation in such activities and/or use of such equipment may result in personal property damage and/or injury and/or illness and/or death; (c) these risks and dangers may be caused by other participants, or by accidents, or by the forces of nature, or by other persons and/or other causes. Risks and dangers may arise from foreseeable and/or unforeseeable causes that are inherit hazards and dangers of any activity or program taking place in an outdoor and/or recreational environment including while transporting to and from said activities; and (d) I hereby accept and assume these risks and dangers.

I hereby affirm that my child is not allowed to use nor be under the influence of alcohol or controlled substances. I hereby affirm that my child is to obey all safety requirements that govern each activity which include but are not limited to such things as wearing an approved personal flotation device and/or helmet and/or harness and/or gloves. I hereby affirm that my child is not to use nor be in the possession of any tobacco products, dangerous or violent weapons, obscene materials, or any other item or items that may cause personal harm and/or disruption to others.

I understand that strenuous physical exertion may be required and my child has no known physical disabilities or health conditions which will or may present any risk to his or her participation in the activities or programs as provided. I release and agree to indemnify and hold harmless the volunteers, officers, and persons involved with Green Swamp Youth Campers from any and all incidents and/or liabilities to my child's participation in these activities and/or programs to the fullest extent permitted by law, even if arising from negligence. I agree not to press any disputes or claims against the Green Swamp Youth Campers or any person associated with the group. I understand that the Youth Campers have no physical or monetary assets and that individual that volunteer their time and possessions do so on the grounds that I will not hold anyone liable for volunteering so that the group may function. I understand that the Green Swamp Youth Campers is not a legal entity, is not incorporated, and has no assets. I understand that the volunteers do so as Good Samaritans trying to provide worthwhile activities for young people and as such are protected by law, the Good Samaritan Law, against lawsuits.

I hereby permit the activity and/or program coordinators and its agents to photograph, post online, videotape, or by any other means record my child's image or voice or writings for the purpose of instructional, promotional, or archival use.

The above agreement shall be binding on my heirs, successors, assigns, administrators and executors.

I HAVE READ THE ABOVE AND BY SIGNING IT AGREE THAT IT IS MY INTENTION TO GRANT PERMISSION FOR MY CHILD TO PARTICIPATE IN GOING THE GREEN SWAMP YOUTH CAMPERS ACTIVITIES AND/OR PROGRAMS, AND TO ASSUME AND ACCEPT ALL ASSOCIATED RISKS.

CHILD's PRINTED NAME:___________________________________________________ AGE: _______________

CHILD's SIGNATURE: _____________________________________________________ DATE: ______________

PARENT/GUARDIAN's PRINTED FULL NAME: _______________________________________________________

PARENT/GUARDIAN's SIGNATURE: ___________________________________________ DATE: _____________

Notarization Required

State of Florida, County of __________________

I hereby certify that the forgoing was executed before me this__________day of __________, 20______

by _____________________________ who is:

___ personally known or ____ who has produced ________________________ as identification.

____________________________________

Notary Public, State of Florida