Daughter/Participant’s Name *

First Name

Last Name

Parent/Legal Guardian’s Name *

First Name

Last Name

Cellphone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Confirm by Checking All Three Boxes: *

I hereby attest that I am the parent or legal guardian of the participant named above, and I have carefully read, understood, completed and signed this consent form.

I understand and agree that my daughter’s cell phone will be kept in a safe box and will only be made available to her for an hour after the day’s activity close-out.

I understand and agree that if my daughter does not follow the rules of GEMBHAM or exhibits disrespectful and rude behaviors, I will have to pick her up from camp early.

My daughter may be given over-the-counter pain relievers or allergy medications, if needed. *

Yes

No

I understand and agree that photographs and videos taken during the retreat’s group activities may include my daughter named above, and may be used for GEMBHAM Retreat’s promotional or educational purposes only. *

Yes

No

My daughter may attend instructional group sessions conducted by expert educators from Walker County on human trafficking awareness and social media safety, and the Crisis Center on suicide prevention and domestic abuse support. *

Yes

No

My daughter may participate in guided and supervised outdoor group activities, including team building, high ropes/low ropes, and canoeing. *

Yes

No

My daughter is in good health and has no physical or medical limitations that would cause the activities above to be detrimental or dangerous to her. I understand that activities of the kind described above may result in physical injury to participant but nonetheless specifically request that she be allowed to participate in those activities. *

Yes

No

Confirm by Checking Both Boxes: *

I understand that I will be notified should a health emergency arises. If I cannot be reached by telephone, I hereby authorize whatever medical treatment is deemed necessary by medical personnel.

I represent that my daughter is (a) covered by insurance through my own insurance carrier; or (b) that I am personally financially responsible for any and all medical costs incurred as a result of her injury.

Parent/Legal Guardian Signature *

First Name

Last Name

Date *

MM

DD

YYYY