As an adult camp worker or as a parent/guardian of a Minor camper listed above, I grant permission for the registered camper to attend the Church of God State Camp and consent to its Discipline Policy.*

I do hereby release the Pollock Campground Association, Inc. (Church of God State Camp) and the Louisiana Congregational Ministries of the Church of God, Inc. from any and all liability or responsibility due to any injury that I or my camper may incur as the result of or arising in any way from participation in activities at or under the direction of the Pollock Campground Association, Inc. *

I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. *

I understand the Pollock Youth Camp staff often take photos and videos of participants during camp events without compensation and that these approved photographs or videos may be used in publications, presentations, websites, or promotions of the Pollock Campground Associations, Inc. I understand the Pollock Youth Camp will not identify me or my child by name or release any other personal information with out written permission from me.*

I, hereby give permission for the Camp Nurse to administer the following over-the counter medications if the nurse deems it necessary. Dosages will be administered according to directions on the bottle unless a physician directs otherwise.

Tylenol or Ibuprofen for Headaches

Pepto Bismol for Upset Stomach/Nausea

Imodium AD for Diarrhea

Ibuprofen for Menstrual Cramps

Calamine Lotion for Poison Ivy

Benadryl for Allergic Reactions

Neosporin or Triple Antibiotic Ointment for superficial wounds*

In the event I cannot be reached in an emergency, I hereby give permission to the Camp Director/Camp Nurse to secure the services to provide the care necessary to treat my child, including hospitalization and/or anesthesia if required.*

I give permission for the Camp Nurse to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child.*

I, the undersigned parent/guardian of the minor child, listed above, a camper at Pollock Campground Association, request that he/she be given medication as prescribed according to the prescribing Medical Provider under the supervision of the Camp Nurse during the duration of the camping event.*

I, the undersigned parent/guardian of the minor child, named above, hereby give permission to the Camp Nurse selected by the Camp Director to provide routine health care which may include nursing assessment, administration of first aid and/or administration of routine or as needed medications. *

I understand that the medicine is to be supplied by me in an appropriately labeled prescription bottle. I have administered each medication at home and have allowed sufficient time for observation of adverse reactions before asking the Camp Nurse to administer the medication.*

I hereby release, relieve, and discharge Pollock Campground Association and/or the designated Camp Nurse from any and all liabilities for any injury or damage to the health of the said child arising out of, or resulting from, the necessity of the said child having to take medication while attending the camp event.*