The SayPro Medical Waiver and Consent Form is a critical document required for each participant or their guardian to complete before attending the 5-Day Visual Arts Camp (January SCDR.4.4.1). This form serves as both a medical waiver and consent agreement, ensuring that all participants’ health and safety needs are addressed and that they are authorized to engage in the activities planned for the camp.
The form is designed to collect important information related to medical history, any allergies or special needs, and provide informed consent for participation in the camp’s activities, including painting, drawing, sculpture, and other visual arts techniques. It also releases the camp organizers and instructors from liability in case of medical emergencies or accidents.
This form must be submitted prior to the camp’s start, either digitally via SayPro’s platform or as a printed document, and it will be kept on file for reference throughout the duration of the camp.
1. Participant Information
This section collects basic identifying information for the participant and their guardian (if applicable).
- Full Name of Participant: _______________________________
- Date of Birth: _______________________________
- Age: _______________________________
- Gender: _______________________________
- Emergency Contact Name: _______________________________
- Emergency Contact Phone Number: _______________________________
- Relationship to Participant: _______________________________
If the participant is under the age of 18, the following guardian information is required:
- Full Name of Guardian: _______________________________
- Guardian’s Relationship to Participant: _______________________________
- Guardian’s Phone Number: _______________________________
2. Medical Information
This section collects information on the participant’s medical background, including any chronic conditions, allergies, and medications they may be taking. This helps ensure that the camp staff can accommodate the participant’s health needs during their time at the camp.
- Does the participant have any allergies?
(Please check all that apply and provide details)- Food Allergies: _______________________________
- Medication Allergies: _______________________________
- Environmental Allergies (e.g., pollen, dust): _______________________________
- Other: _______________________________
- Does the participant have any chronic health conditions?
(Please check all that apply and provide details)- Asthma: _______________________________
- Diabetes: _______________________________
- Epilepsy/Seizures: _______________________________
- Heart Conditions: _______________________________
- Mental Health Conditions: _______________________________
- Other: _______________________________
- Is the participant currently on any medications?
- Yes
- No
If yes, please list the medication(s) and reason for use: - Medication Name(s): _______________________________
- Dosage/Instructions: _______________________________
- Does the participant have any physical, emotional, or psychological conditions that might require special accommodations or attention during the camp?
- Yes
- No
If yes, please explain: _______________________________
3. Consent for Participation
This section asks for the participant or their guardian’s consent to participate in the camp, acknowledging understanding of the camp’s activities and any associated risks.
By signing below, the participant or their guardian confirms that they understand the nature of the 5-Day Visual Arts Camp activities, including but not limited to painting, drawing, sculpture, and the use of various art supplies and tools, and agree to the following:
- I, the undersigned, grant permission for the participant to engage in all activities related to the 5-Day Visual Arts Camp, including the use of art materials, tools, and equipment such as paints, brushes, knives, sculpting tools, etc.
- I acknowledge that while all reasonable precautions will be taken to ensure the safety of the participant, there are inherent risks associated with creative activities (e.g., cuts, scrapes, allergic reactions, etc.), and I release SayPro and its staff from any and all liability for injuries or accidents that may occur during the camp.
- I consent to the participant’s participation in supervised outdoor or indoor activities, including but not limited to field trips (if applicable), and fully understand the potential risks involved in such activities.
- I grant SayPro permission to administer first aid if necessary and to contact emergency services in case of an accident or medical emergency.
Signature of Guardian (if participant is under 18): _______________________________
Date: _______________________________
Signature of Participant (if over 18): _______________________________
Date: _______________________________
4. Medical Emergency Authorization
This section grants permission for medical intervention in case of an emergency.
In the event of an emergency where medical treatment is required, I authorize the camp staff to seek medical attention for the participant. I also acknowledge that I am responsible for any costs associated with medical treatment during the camp.
- Preferred Medical Facility: _______________________________
- Physician’s Name: _______________________________
- Physician’s Contact Information: _______________________________
- Insurance Provider: _______________________________
- Policy Number: _______________________________
5. Photo and Media Release Consent
This section provides consent for the use of photos or videos taken during the camp for promotional or educational purposes.
- I, the undersigned, consent to the use of photos or video recordings of the participant taken during the 5-Day Visual Arts Camp for the purposes of promotion, educational materials, or digital content (e.g., website, social media, etc.).
- Yes, I give consent.
- No, I do not give consent.
Signature of Guardian (if participant is under 18): _______________________________
Date: _______________________________
6. Participant Code of Conduct Agreement
This section ensures that the participant understands and agrees to adhere to the camp’s code of conduct and behavior expectations.
- I agree to follow all rules and regulations set by the camp staff, respect others, and participate actively in all camp activities.
- I understand that failure to follow the code of conduct may result in removal from the camp without a refund.
Signature of Participant: _______________________________
Date: _______________________________
7. Camp Liability Waiver
This section releases SayPro and its staff from any liability for damages or injuries sustained during the camp.
- I, the undersigned, agree to indemnify and hold harmless SayPro, its employees, agents, volunteers, and any other affiliated individuals from any and all liability for injuries or damages arising from my participation in the 5-Day Visual Arts Camp.
Signature of Guardian (if participant is under 18): _______________________________
Date: _______________________________
8. Acknowledgment
By signing this form, I acknowledge that I have read and understood all the information provided in the SayPro Medical Waiver and Consent Form. I understand the camp’s medical, liability, and behavior policies, and I consent to the terms outlined above.
Signature of Guardian (if under 18): _______________________________
Signature of Participant (if over 18): _______________________________
Date: _______________________________
Conclusion
The SayPro Medical Waiver and Consent Form ensures that all participants’ health, safety, and well-being are addressed prior to the 5-Day Visual Arts Camp. By collecting necessary medical information, obtaining consent for participation, and establishing clear expectations, this form helps to create a secure environment where participants can freely explore their creativity through painting, drawing, sculpture, and other visual arts techniques.
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