CAMPER INFORMATION

FAMILY INFORMATION

Spouse Information (Optional)

MEDICAL HISTORY - EMERGENCY CONTACTS

MEDICAL HISTORY - MEDICATIONS

  • Prescription medications MUST be in the original pharmacy labeled container or the original manufacturer’s container.
  • Prescription medications MUST have your attendee’s name on the bottle.
  • Any doctor’s office samples MUST be accompanied by a signed physician prescription.
  • Please limit the amount of medication to only what is required for your attendee's term.
  • Our Health Center provides most common over the counter medications. Please do not send these to Camp Grace.

MEDICAL HISTORY - INSURANCE

MEDICAL HISTORY - ALLERGIES

MEDICAL HISTORY - RELEASE

Medical and Liability and Image Release

The undersigned represents to Vision Atlanta / Camp Grace (herein referred to as VA, a non-profit organization, that he/she is the legal guardian and natural parent or the legal guardian of the above named child; and the undersigned does hereby consent to such minor taking part in the Vision Atlanta Camp Grace, with full understanding that insofar as such activity will involve but is not limited to traveling to and from camp in vans or busses, eating food prepared by camp staff or local restaurants, swimming, horseback riding, camp sports which includes high ropes courses, archery, that there is always the risk of injury, illness, loss, death, and possible consequent expenses for the medical, diagnostic, and curative treatments, and incidental loss and expense, and the undersigned does for him/herself and for and on behalf of such minor assume the risk of such expense and does hereby wholly release VA and any representative from any responsibility or liability; and waives any claims or causes of action against it or its agents that might rise on account of loss, injury, death, or expense occasioned by any sort of accident or any other circumstances involving such child, and agrees to hold harmless in event any such claim should arise; and the undersigned agrees to abide by the rules and regulations, supervision and discipline set applied by VA and its agents, and does hereby authorize VA or its representatives or other agents to arrange for any needed medical treatment or x-rays, and hold harmless VA from any such expenses. The undersigned will reimburse VA fully or furnish payment or insurance for any such payment, at his or her own expense. The undersigned also agrees to pay in full for any property damage caused by his/her own child. Permission is also given to the camp nurse or doctor to administer over the counter medication to the above named child as needed. The undersigned also gives permission to VA to use any image, video or written material that the above named child is in or wrote. Images and videos will be used for the sole purpose of promoting the camp and not for financial gain. The undersigned understand that the directors of VA reserves the right to dismiss any camper (at the urban partner’s expense) who completely disregards the authority set in place at Camp Grace or whose influence and conduct becomes in any way detrimental to the best interests of other participants and staff at Camp Grace.