ACTIVITY RELEASE FORM Permission to Video

143 N. Nichecronk Road Dingmans Ferry, PA 18328
Web: www.campspeersymca.org
Email: [email protected]
Toll Free: 877-SPEERSY
Phone: 570-828-2329
FAX: 570-828-2984
This form must be signed and returned to the Camp Speers-Eljabar YMCA camp office
a minimum of two weeks prior to your arrival at Camp Speers-Eljabar YMCA.
Dates at Camp Speers-Eljabar YMCA ___6/29/11_________
Participating as part of the Westfield Area Y Teen Camp Program.
ACTIVITY RELEASE FORM
Permission for Enrollment of Minor (under age 18) and Release of YMCA from Liability: I am an adult over
the age 18 years of age and am duly authorized to grant permission for (child’s name) _____________________ to
participate in all Camp Speers-Eljabar YMCA activities and to release the YMCA and its staff members from all
liability for any injury, loss and/or damage connected in any way whatsoever with participation in YMCA activities
whether on or off the YMCA’s premises. I understand that this release includes any claims based on negligence,
action or inaction of the YMCA, its staff, directors, members and guests. I understand that even when every
reasonable precaution is taken, accidents can sometimes still happen. I certify that this child is capable of
participating in an active recreation experience. I understand that a well-rounded experience at Camp SpeersEljabar will offer a variety of activities. I understand that at any time a participant may opt out of an activity. I have
read and agree to provisions outlined in this document.
_________________________________________
Signature of adult
______________
date
_________________________
relationship to child
Address: ____________________________________________________________________________________
Email: ______________________________________________________________________________
Permission to Video Tape and Photograph
I hereby grant permission for my child __________________________to be video taped and/or
photographed while participating in programs and activities of Camp Speers-Eljabar YMCA. It is my
understanding that video taping and photographs will be used for educational, training and promotional
purposes only. I may revoke this permission at ant time be sending a letter to Camp Speers-Eljabar
YMCA.
I do not grant permission for my child to be video taped and/or photographed while participating in
programs and activities of Camp Speers-Eljabar YMCA.
_________________________________________
Signature of adult
______________
date
_________________________
relationship to child