Joshua Center for Neurological Disorders
7611 State Line Road, Suite 142, Kansas City, MO 64114
816-763-7605  Fax: 816-763-1802

Joshua Center Camp
Release of Liability and Press Release

For Joshua Camp Held At The Rotary Youth Camp
22310 E. Colbern Rd., Lee’s Summit, MO 64063

Release of Liability

The undersigned releases the Joshua Center for Neurological Disorders, its staff members, its agents and representatives, its officers and employees and its Board of Directors from all liability for any injury to camper/myself as staff member from participation in the Joshua Center Camp.

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

Photo/Media Release

I hereby authorize and give my permission for any community newspaper interviews, television interviews, or photos of my child or myself to be used exclusively for the use of said newspaper, television station, Rotary Camp, or the Joshua Center for Neurological Disorders.

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

Counselor Meeting Release

I herby authorize and give my permission for my child to meet with our staff counselor or identified individual to provide support during difficult times either individually or in a group setting.

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

Joshua Center Camp
Release of Liability and Press Release
Page 2

Camp Activities Release

I herby authorize and give my permission for my child to participate in the following camp activities:

Arts and Crafts    Archery    Sling Shots   Swimming 

Team Building    Scavenger Hunt   Animal Program

Camp Fire    Painting   Cook Out    Fishing by the lake Pontoon

Boating/swimming in Lake Jacomo

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

View Medical Records Release

The undersigned gives permission for the Joshua Center for Neurological Disorders Camp Staff and Emergency Personnel at Truman Medical East to view the medical information provided on the ACA Camp Health History Form for the benefit of my child.

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

Camper Refund Agreement

I understand that I am due a camp refund (minus $50 registration fee and prorated by attendance) for my child only if the emergency involves injury or illness to my child or if there is a death to a family member.

Date:   Child’s Name 

Parent/ Guardian’s Signature _____________________________________

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