Please fill out the information below if you plan to serve at any events at Camp Lighthouse for 2024. This form only needs to be filled out once for this date range.
Volunteer & Contact Information
The following questions need to be filled out by a parent/guardian of the counselor, if they are under 18, or the counselor/volunteer, if they are over 18.
The following information is for the Camp Nurse. ALL medications will be managed by the Camp Nurse. This is to protect campers from finding any medication during camp. Any medications the counselor will need while at camp, other than the over-the-counter medications listed below, need to be labeled with the counselor’s name and must be in the original bottle/package (may be open). Camp Lighthouse can provide the following over the counter medications to the counselor during camp and will be administered by the Camp Nurse based on height and weight.
Fill out the following questions if the counselor takes any medications on a regular basis that will be brought to camp besides the over-the-counter medications provided by the Camp Nurse. Include prescription medications and over-the-counter medications not provided by the Camp Nurse. List Medication, Dosage, and when the medication is taken (morning, noon, evening, before bed, etc.)
Acknowledgement of Camp Policies
Please select all that apply.
Please read and initial after each section below.
PERMISSION TO OBTAIN MORE INFORMATION
I, the undersigned parent of a minor, or I, myself, authorize Camp Lighthouse and/or its agents to conduct an independent background investigation. I further authorize Camp Lighthouse and/or its agents to request or receive any information including criminal, motor vehicle reports, past employment, education and/or references from any persons, schools or previous employers. I verify that the answers of the legal questions on this form are true. I understand that if any misstatement of fact on this form is discovered, the counselor will be removed from serving.
ASSUMPTION OF RISK
In consideration for being permitted to participate in any and all educational/ recreational/religious activities (the “Activities”) conducted or administered by Romans12, LLC, dba Camp Lighthouse, a Georgia limited liability company ("Camp Lighthouse"), or its owners, members, managers, directors, officers, representatives, agents, employees, contractors, volunteers, Affiliates (as defined below), or any of their successors in interest (the "Released Parties") at Camp Lighthouse (the "Premises") which are contemplated or scheduled to take place on or about the Premises during the period of time from July 1, 2024 to January 31, 2025, and transportation to and from the Premises, on behalf of themselves and agent for the Counselor and the respective heirs, successors, assigns and legal representatives of all such persons (collectively, the "Releasing Parties"), I, the parent or guardian of the participant (“Parent of counselor”) do hereby irrevocably release and waive any and all past, present or future claims, demands, or causes of action which any Releasing Party now has or may in the future have against Camp Lighthouse or any of the Released Parties, for any and all past, present or future loss of or damage to person or property, including but not limited to sickness (including but not limited to COVID-19), bodily injury and death, however caused, with respect to the counselor, resulting from or arising out of or in any way connected with the Activities, including but not limited to travel associated therewith. As used herein, the term "Affiliate" of an individual or entity shall mean, (a) in the case of an individual, any relative or business associate of such individual, and (b) in the case of an entity, any person or entity directly or indirectly through one or more intermediaries controlling, controlled by or under common control with a person or entity who or which is otherwise protected by the terms of this agreement.
HOLD HARMLESS
In addition, in consideration for the counselor being permitted to participate in the Activities, the undersigned, on behalf of their counselor and as an agent for each of the Releasing Parties, hereby agree to indemnify and hold harmless each of the Released Parties, as well as any organization sponsoring the counselor’s participation in the Activities, from and against any and all claims and liabilities related to the counselor’s participation in the Activities. In the event of any emergency relating to the counselor during or in connection with the Activities, the undersigned hereby authorizes any adult leader of Camp Lighthouse, as an agent for each of the releasing Parties, to consent to any X-ray examination, emergency transportation, medical, dental, surgical, diagnosis, treatment, or hospital care advised and supervised by any physician, surgeon, or dentist (an appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. The undersigned, on behalf of the Counselor and as agent for each of the Releasing Parties, further assume all responsibility for the medical decisions so made and agree to be fully financially responsible for any and all medical, hospital, and/or emergency treatment so secured for the counselor.
VIDEO & PHOTO RELEASE
In addition, the undersigned, on behalf of the counselor and as agent for each of the Releasing Parties, hereby authorizes Camp Lighthouse and those acting pursuant to the authority of Camp Lighthouse to record the counselor's likeness and voice in any medium, use the counselor’s name in connection with these recordings, and use, reproduce, exhibit or distribute in any medium such recordings for any purpose, including but not limited to any promotional, recruitment and fundraising programs that Camp Lighthouse deems appropriate, including promotional or advertising efforts. The undersigned, on behalf of the counselor and each of the Releasing Parties, hereby further release Camp Lighthouse from any liability for any violation of any personal or proprietary right that the counselor or any of the other Releasing Parties may have in connection with such use. The undersigned, on behalf of the counselor and each of the Released Parties, hereby acknowledge that all such recordings, in whatever medium, shall remain the exclusive property of Camp Lighthouse.
PERMISSION TO TREAT
I hereby give permission to Camp Lighthouse to supervise/assist in the administering of over-the-counter medications marked approved on the online counselor Registration Form. I hereby give permission to Camp Lighthouse to supervise/assist in the administering of the prescription medications listed on the counselor Registration Form. I release Camp Lighthouse and its volunteers from any liability for administering over-the-counter and prescription medications to my counselor while at Camp Lighthouse.
PERMISSION TO TRANSPORT / TREAT IN AN EMERGENCY
I hereby give permission for my counselor to be transported to and from Camp Lighthouse, in the event of an emergency. I do hereby release Camp Lighthouse, Mount Pisgah UMC, and all adult staff and volunteers from any liability in the event of any accident in route, during, and returning from an emergency facility. I also give permission for my counselor to be examined, x-rayed, and treated by any licensed medical facility, office, hospital, or emergency facility, if in the judgment of the directors, nurse, and volunteers, it is determined that emergency care is required to insure my counselor’s health and well being.