Check the appropriate response to the questions below:

Did your child ever have Chicken Pox? Yes _______ No______ Has your child been tested for Tuberculosis? Yes _______ No______ Does your child suffer from chronic ear infections? Yes _______ No______ If yes, is the child permitted to participate in swim activities? Yes _______ No______ Does your child use an inhaler? Yes _______ No______(If yes, fill out Medical Dispensation form) Does your child require sunscreen or need to stay in shaded areas when outside? Yes _______ No______ Should your child’s activity be restricted due to any physical difficulty or illness? Yes _______ No______ If yes, please explain degree of restriction below:

 We Hereby Consent

 1. We consent and authorize the St. Peter the Aleut Summer and/or YMCA Camp Grady Spruce Health Officer/ Nurse to provide treatment whether en route, on, or off the camp grounds for any first aid whether routine or emergency, including, without limitation, injury, illness, choking, etc.

2. We and each of us consent and authorize the YMCA Camp Grady Spruce and St. Peter the Aleut Summer Camp lifeguards/ Water Safety instructors to provide treatment, including cardiopulmonary resuscitation (CPR) in the event of a water sports accident or other need.

3.If we parents/guardians cannot be reached in case our child had an emergency or other medical need, we and each of us hereby appoints, authorizes, and constitutes the St. Peter the Aleut Camp Director, Camp Health Officer/ Nurse, or other duly authorized staff member to act in our behalf as parents to authorize and consent to medical treatment for our child/ren named herein:

___________________________________________________________________________ including authorizing surgery. In case of need, we authorize any family or specialist physician, dentist, or other licensed health care professional, and also any licensed health care facility to provide any and all necessary treatment to our child.

 The below consent and authorization includes routine, emergency, inpatient, and outpatient care. Any health care professional or health care facility is authorized to accept and rely on the St. Peter the Aleut Summer Camp Staff’s representation if we cannot be reached. The original form shall be displayed to a health care provider, but this original shall remain in the custody of the Camp Director.

In addition, I agree that in the case of a health or accident emergency, or any other situation which might arise en route to and from camp, or while attending camp, that none of the faciltators, staff or sponsors of the St. Peter the Aleut Summer Camp, including but not restricted to the YMCA Camp Grady Spruce, The Orthodox Church in America, The Diocese of the South, St. Seraphim Orthodox Cathedral or its staff, volunteers or representatives will be held liable in any way. 

Witness: ___________________________ Signed ______________________________

                                                                                                Parent/ Guardian

Witness: ___________________________ Signed ______________________________

                                                                                                Parent/ Guardian

Date: ______________________________