Camp Blue Haven

Camp Blue Haven Authorization Form


2021 Session ____   Cabin ____   (Office use only)

 

Camper Last Name:

Camper First Name:

Middle Initial:

 

Insurance Authorizations

Initial: Authorization to pay insurance benefits directly to the provider of medical services: Brotherhood Mutual is a secondary policy provided to all campers by Blue Haven Youth Camp Inc.. I hereby authorize that the insurance benefits payable to me by Brotherhood Mutual Insurance Company be paid directly to the medical provided.

Initial: The health history I have provided to Blue Haven Youth Camp Inc. is correct to the best of my knowledge, and my child has permission to engage in all camp activities, including but not limited to: hiking, ropes/challenge course, and sports—except as noted on this form.

Initial: In the event that I cannot be contacted in an emergency, I give permission to Blue Haven Youth Camp Inc. or its designated representative to provide consent for my child to receive hospitalization, treatments, injections, anesthesia, or surgery. I further give my consent for Blue Haven Youth Camp Inc.or its designated representative to administer any needed “over-the-counter” medications, except as I have noted on this form.

 

Insurance Information

Insurance Provider:
Policy Number:
Group Number:
Policy Holder Name:
Policy Holder Phone:
Employer:
Employer Phone:

 

*Please have a digital copy or scanned image of your insurance card available if requested

 

PROHIBITED ITEMS

For the current list of prohibited items, please refer to our Code of Conduct available at: https://campbluehaven.com/camprules

The Blue Haven Youth Camp Inc. Code of Conduct applies to all campers, parents/guardians, and visitors and is subject to change without notice.

 

PARENT/CAMPER CONSENT

Blue Haven Youth Camp, Inc. has put preventative measures in place to help reduce the spread of COVID-19 as recommended by the CDC and state health agency(s); however, the health and/or wellness of any individual before, during, or after attending Blue Haven Youth Camp, Inc. cannot be guaranteed.

Initial: I (we) acknowledge and voluntarily assume the risk of exposure to any disease, infection, or virus (including but not limited to COVID-19), associated with being physically present in any public setting and that such exposure, and/or infection could result in personal injury, illness, disability, and death. I (we) also acknowledge and voluntarily assume that the risk of exposure, illness, and/or infection at Blue Haven Youth Camp, Inc. may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Blue Haven Youth Camp, Inc. employees, other campers, vendors or affiliates and their families.

Initial: I (we) agree to release, protect, defend, indemnify and hold harmless Blue Haven Youth Camp, Inc. and its trustees, officers, employees, and other representatives from and against any and all claims, liabilities, losses, damages, actions, costs and expenses (including without limitation, reasonable attorney's fees and other legal costs) directly or indirectly arising out of their attendance of the respective camp session(s) of Blue Haven Youth Camp, Inc. and their use of any of Blue Haven Youth Camp, Inc. facilities and activities regardless of whether such claims, liabilities, losses, damages, actions, costs and expenses (including, without limitation, reasonable attorney's fees and other legal costs) result from the negligence of Blue Haven Youth Camp, Inc. (including its trustees, officers, employees, and other representatives) or otherwise.

Initial: I (we) concur by signing below, that while on Blue Haven Youth Camp, Inc. property and/or participating in Blue Haven Youth Camp, Inc. activities, camper (and/or parent/guardian if applicable) has (have) received, reviewed, and agree(s) to adhere to the Code of Conduct https://campbluehaven.com/camprules and Statement of Faith https://signup.campbluehaven.com/SOF/SOF.pdf

 

Today's Date:

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Signature Certificate
Document name: Camp Blue Haven Authorization Form
lock iconUnique Document ID: 888f474878a1e91749878b1925571b7e3478fc22
Timestamp Audit
May 20, 2021 6:02 pm MDTCamp Blue Haven Authorization Form Uploaded by Vance Lucero - admin@campbluehaven.com IP 75.70.245.170