Check the appropriate response to the questions 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: ______________________________