Camp Blue Haven

Camp Blue Haven Authorization Form


2022 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 in the camper medical 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 noted in the camper medical 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

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) acknowledge and voluntarily assume the risk of exposure to any disease, infection, or virus 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) 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: November 28, 2022

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Signature Certificate
Document name: Camp Blue Haven Authorization Form
lock iconUnique Document ID: 444c79dd9c9e9280bda78561e32e561a60351a2a
Timestamp Audit
May 20, 2021 6:02 pm MSTCamp Blue Haven Authorization Form Uploaded by Vance Lucero - admin@campbluehaven.com IP 50.26.169.45