Test Holiday Form

I hereby grant participant named above permission to participate in all activities offered by or through Wayfinder Family Services, with the exception of those activities indicated above. The undersigned parent, guardian, or custodian of the above named participant hereby joins in the foregoing Activity Opt-Out Form and hereby stipulates and agrees to save and hold harmless, indemnify, and forever defend Wayfinder Family Services, their directors, officers, agents, employees, and volunteers from and against any claims, actions, demands, expenses, liabilities (including reasonable attorney fees) for negligence as a result of said participant’s participation in the activities of Wayfinder Family Services and his or her use of the property, animals, and facilities. I, on behalf of said participant, further agree not to sue Wayfinder Family Services, its directors, officers, agents, employees, and volunteers as a result of any injury that said minor suffers from negligence in connection with his/her participation in the activities of Wayfinder Family Services.

The undersigned parent/guardian represents to Wayfinder Family Services that the minor named in this application is in his and/or her legal custody and control; and that the undersigned desires said minor to participate in the programs of Wayfinder Family Services, and that for purposes of said participation the undersigned agrees, authorizes and states as follows:

In case of medical or dental need or emergency, I (we) understand every effort will be made to contact parents/guardians of children. In the event I (we) cannot be reached, I (we) undersigned, parents/guardians of camper, do hereby authorize Wayfinder Family Services and its officers or staff employees as agent(s) for the undersigned to obtain and consent to any x-ray examination, anesthetic, medical, dental, surgical diagnosis, treatment and hospital care which is deemed advisable by, and is to be rendered to said minor under the general or special supervision of any surgeon licensed under the provisions of the Medical Practice Act or the medical staff of a licensed hospital or by a dentist licensed under the provisions of the Dental Practice Act, whether such diagnosis of treatment is rendered at the office of said physician or dentist or at the said hospital.

I (we) also understand and agree that any and all such medical, dental, hospital or similar expenses incurred in the treatment of my (our) child will be borne by myself (ourselves). We understand that no representation of such coverage exists or is intended by this form.

It is understood that this authorization is given in advance of any specific medical or dental diagnosis, treatment or care being required but is given to provide authority and power on the part of Wayfinder Family Services (as aforesaid) as my (our) agent(s), to give specific consent to any and all such diagnosis, treatment or care which a licensed physician or dentist in the exercise of his/her best judgment may deem advisable. The authorization is given pursuant to the provisions of Sections 25.8 of the Civil Code of California.

This authorization shall remain effective while the child is enrolled in Wayfinder Family Services’ Recreation Programs, unless sooner revoked in writing and delivered. The undersigned further releases Wayfinder Family Services, its officers, agents, and employees from any and all legal responsibility for accidents or sickness occurring during or related to the period of time said person is a participant in programs of Wayfinder Family Services. I (we) further agree and covenant (for valuable consideration, receipt of which is acknowledged) that neither said person or I (we) will institute any suite or action of damage, loss or injury of any kind, whether to person or property, whether to me (us), individually, or as parents/guardians relating to the programs or activities of Wayfinder Family Services (including but not limited to Camp Bloomfield) in which the person participates.

Current Medical Insurance is mandatory in order to participate in any recreation activity or event. Any medical costs incurred while participating in any Wayfinder Family Services’ Recreation Program (including Camp Bloomfield) shall be the responsibility of the participant’s parent or guardian. Medical costs include: physician visit, emergency room visit, prescription medication, and/or emergency transportation. It is also to be understood and agreed that any and all such medical, dental, hospital, or similar expenses incurred in the treatment of the participant will be borne solely by the parent or guardian. If a situation requires medical treatment, the parent or guardian will be contacted by a staff member and informed of the situation. Should a situation arise where the parent or guardian cannot be reached, the participant will be taken to the local emergency facility for treatment.

This is an Agreement to mediate and arbitrate all unresolved disputes arising from the educational, recreational, special education school, and residential services between the undersigned camper and/or their legal guardian and the Wayfinder Family Services.

Permission is hereby given to WAYFINDER FAMILY SERVICES® to use audio, video recordings, photographic and electronically created images of the camper noted in this application for public view, including publications, websites or social media sites. Usage of any images or audio is without compensation to said person or to the undersigned on his/her behalf, or individuality.