Camp or Clinic Participant Acknowledgments, Authorizations, and Releases: Recommended Form

Note: The following form is a sample and assumes use of parent insurance coverage. Identify policy areas that require the review of higher authorities and present those questions and issues to your administration. Customize for your institution and have the document reviewed by institutional legal counsel or higher administration to ensure consistency with local, state, and federal laws and institutional policy.

Name of participant: ____________________________

Address: _____________________________________

City: ________________________ St: ___ Zip: ______

Camp or clinic: _________________________________

Dates of attendance: ____________________________

Name of parent or guardian living with camper: ________________________

Relationship: ___________________________________

Daytime contact phone: ___________________________

Evening contact phone: ___________________________

E-mail: ________________________________________
 
NOTE: All camp participants are required to complete and submit the following documents before being permitted to participate: (1) the following release from liability form, (2) proof of insurance, and (3) medical information and physician clearance for participation.

I/we hereby give consent for my/our child or ward to participate in the above-named sport camp or clinic. I/we know of, and acknowledge that my/our child or ward knows of, the risks involved in athletic participation; understand that illness, serious personal injury, and even death is possible in such participation; and choose to accept all responsibility for his or her safety and welfare while participating in athletics.

With full understanding of the risks involved, I/we, the undersigned, hereby release and hold harmless the [name of institution] and its successors, assignees, officers, agents, and employees from all liability, costs, claims, demands, actions, and causes of action whatsoever in any way growing out of or resulting from my child or ward’s participation in this camp or clinic.

I/we authorize emergency medical treatment for my/our child or ward should the need arise for such treatment while my/our child or ward is under the supervision of the [name of institution]. In addition to authorizing emergency medical treatment, I/we hereby grant my permission to qualified health care professionals (including athletic trainers and medical staff) to administer immediate treatment to my/our child or ward should such care be deemed professionally necessary and to disclose my health information to [name of institution] athletic trainers, physicians, and staff and any medical service, allied health, or hospital services personnel arranged for by such [name of institution] athletic trainers, coaches, or other personnel. I/we understand that [name of institution] officials are not responsible for administering any nonprescription medications and have my permission to dispense prescription medication according to instructions that appear on the Medical Information and Physician Clearance for Camp or Clinic Participation form. 

I/we understand that the athletic department does not provide medical insurance covering injuries of any nature incurred in camp or clinic activities, transportation related to camp or clinic activities, medical care transportation, or other costs associated with such injuries. I/we understand that for the above-named participant to be permitted to try out or participate in athletics, I/we must show proof of insurance coverage. I/we have completed the [name of institution] Camp or Clinic Participant Proof of Insurance form, which indicates the specifics of my/our coverage under my/our family insurance policy or insurance purchased by me/us. In addition to showing proof of insurance coverage, I/we also understand that I/we must submit a Medical Information and Physician Clearance for Camp or Clinic Participation form that verifies that the participant is in good health to participate.

I/we authorize the following adults to sign in, sign out, and pick up this participant:

Name: _________________________________________

Relationship: ____________________________________

Phone (day): ____________________________________

Phone (evening): _________________________________

Name: _________________________________________

Relationship: ____________________________________

Phone (day): ____________________________________

Phone (evening): ________________________________

Name: _________________________________________

Relationship: ____________________________________

Phone (day): ____________________________________

Phone (evening): _________________________________

I/we understand that the authorizations and rights granted herein are voluntary and that I/we may revoke any or all of them at any time by submitting said revocation in writing to [name of institution]. By doing so, however, I/we understand that my/our child or ward will no longer be eligible for participation in this camp or clinic.

I/WE HAVE READ THIS CAREFULLY AND KNOW THAT IT CONTAINS A RELEASE.

____________________________________________________
Name of parent or guardian (printed)

____________________________________________________    
Signature of parent or guardian

Date: _____________________

____________________________________________________
Name of parent or guardian (printed)

____________________________________________________    
Signature of parent or guardian

Date: _____________________

Excerpt from:
Lopiano, D. and Zotos, C.  (2013)  Athletic Director’s Desk Reference.  Champaign, IL:  Human Kinetics.
This publication includes over 300 downloadable forms, risk assessment checklists, and policies and planning tools which are designed to be customizable for your institution.