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2019 SUMMER YOUTH CAMP APPLICATION AND RELEASE

  1. Gender*

  2. T-Shirt Size*

    SIZE NOT GUARANTEED IF REGISTRATION RECEIVED AFTER DUE DATE.

  3. Please read each of the following paragraphs, requesting you select the box next to "I DO", carefully. Indicate your understanding of, and consent to, the contents and conditions for each paragraph by selecting the check box next to "I DO" at the end of each paragraph. Selecting "I DO" will stand place for Initialing on this form. If you have any questions regarding each paragraph, contact the Miami County Sheriff’s Office before "initialing" the paragraph.

  4. I give consent, after all reasonable attempts to contact me, at my phone number listed above, or my spouse, co-legal guardian at the phone number listed above, have been unsuccessful for:*

    (1) The administration of any treatment deemed necessary by the physician or dentist specified below (if any), or in the event the specified practitioner is not available or no practitioner has been specified, then by another licensed physician or dentist; and (2) The transfer of the child to any hospital reasonably accessible.

  5. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for surgery are obtained in writing prior to the surgery.

  6. The following information is needed by any hospital or practitioner not having access to the child's medical history:

  7. Additionally, and in consideration of my above named minor child being permitted by the Miami County Sheriff’s Office to participate in the Program, I do hereby agree to indemnify, release, protect and hold harmless the Miami County Sheriff, the Board of Miami County Commissioners, their deputies, officers, board members, supervisors, agents, servants, employees, and all private persons or organizations volunteering services without charge including supervision, providing instruction, or chaperoning my child during the Program from any claim or liability whatsoever, including, but not limited to, personal injury, property damage, court costs, attorneys' fees and interest, however caused, as a result of my child participating in the Program. If so, agree by selecting the checkbox next to "I DO".*

  8. TERMS OF ACCEPTANCE and SIGNATURE

  9. YOUR ELECTRONIC SIGNATURE BELOW INDICATES YOUR AGREEMENT WITH THE FOLLOWING STATEMENTS: BY TYPING MY NAME IN THE FOLLOWING BOX AND CLICKING THE SUBMIT BUTTON I SOLEMNLY SWEAR THAT ALL OF THE INFORMATION FURNISHED IN THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

  10. I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND AGREE TO THE ABOVE TERMS OF ACCEPTANCE.*

  11. Leave This Blank:

  12. This field is not part of the form submission.