Camper's Name *

First Name

Last Name

Phone *

(###)

###

####

Rash Guard Size *

(Rash guard sizes usually run one size large)

Youth X-Small

Youth Small

Youth Medium

Youth Large

Adult X-Small

Adult Small

Adult Medium

Adult Large

Adult X-Large

Have you surfed before? *

Yes

No

Parent's Name *

First Name

Last Name

Parent's Cell Phone *

(###)

###

####

Swimming Ability *

My child can swim and is allowed in the ocean:

YES

NO

VSM Permission Waiver *

Functions and Activities: Prior to my camper's participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness or even death. I give permission for my student to be transported in an authorized VSM vehicle to VSM activity locations. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Release of Liability: By signing this Permission Waiver, I expressly warrant that the camper named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the student participating in the activities, whether such risks are known or unknown to me at this time. I further release Veritas Shapes Ministries (VSM) and its leaders, employees, Officers, Directors, volunteers, and agents from any claim that my camper may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the student’s or my family or estate, heirs, representatives, or assigns may have against this organization or its leaders, employees, volunteers or agents. I further agree to indemnify and hold harmless VSM and its leaders, employees, volunteers, or agents from any and all claims arising from my camper's participation in its activities and programs, or as a result of injury or illness of my student during such activities. First Aid and Emergency Medical Treatment: I recognize that there may be occasions where the camper named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and secure any needed medical attention or treatment for the camper named above including hospitalization, if in the agent’s opinion that such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for camp staff to give over-the-counter medications as needed, as well as, attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. I give permission for my camper to be transported to a medical center in an emergency situation. Release to use Image and Likeness: On occasion, Veritas Shapes Ministries (VSM) or its representatives takes photographs or makes an audio or videotape recording of campers and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. Local news organizations may hear of our activities or events, and our organization may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the student named above to be used, distributed or displayed as agents of the organization see fit. This consent includes but is not limited to: photographs, videotape and audio recordings. Furthermore, I give permission for the student to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media. In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our activities. These images may also be used by VSM or its agents to produce ministry resources or other uses to promote the ministry of VSM. VSM may also make these materials available for sale to the public.

I have read and agree to the terms above.

Signature of Parent or Legal Guardian *

First Name

Last Name

Birthdate of Parent or Legal Guardian *

MM

DD

YYYY