Medical Authorization and Release of Liability 

    Grace XP Youth Camp
    Neosho, Missouri





    Insurance Information

    This affidavit and Release of Liability made and given this day and year hereinafter set forth by the undersigned, to and for the benefit of Grace XP Youth Camp in Neosho, Missouri. In connection with activity at said camp:
    Beginning on or about July 18 – July 21, 2022
    I certify by my signature below that to my knowledge my child has no conditions or other impediments that would interfere in the safe participation in the above-mentioned activity. I fully recognize the hazards involved in such activities and, by my signature below, voluntarily release, waive, and relinquish any and all actions or causes of actions for my child’s personal injury, property damage or wrongful death occurring as a result of engaging in such activities, or while in transit, and I specifically agree to indemnify and hold harmless Grace XP Youth Camp, Neosho, Missouri, from liability for personal injury, property damage or wrongful death due to the extent that such injuries or damages are attributable to or caused (in whole or in part) by my child’s negligence, misconduct, or violation of normal safety requirements of said activity. I further agree to obey all rules prescribed by the assigned authority of Grace XP Youth Camp involving safety operations of this activity.
    IN THE EVENT OF AN EMERGENCY, INJURY OR ILLNESS, I HEREBY AUTHORIZE GRACE XP YOUTH CAMP TO PROVIDE OR ARRANGE FOR THE PROVISION OF MEDICAL TREATMENT, INCLUDING THE PROVISION OF EMERGENCY FIRST AID, THE ADMINISTRATION OF MEDICATION, OXYGEN, AND OTHER SUCH TREATMENT AS MAY BE NECESSARY UNTIL I CAN BE CONTACTED. I authorize the release of any medical information necessary to process insurance claims. I also request payment to the party who accepts assignment.

    (Please sign in the white box below)