Camp Koinonia Medical Information and Release

Mark every question either Yes or No

Peacebuilders Camp strives to make our summer camp enjoyable and possible for all campers, regardless of any dietary restriction they may have. Our camp kitchen is able to accommodate most restrictions and sensitivities. However, if a camper has a severe condition that requires them to consume a diet entirely composed of highly specialized foods, it may be necessary for them to bring food with them to camp. We will contact you to discuss your child's needs.

I, the camper's parent or legal guardian hereby give Camp Koinonia Staff and Counselors, and Emergency Personnel consent and permission to provide first aid and emergency medical treatment in the event my child is injured during the camp session. I am aware that this medical information form will be kept with the Camp Koinonia counselors, and that Camp Koinonia staff members will take precautions to keep this information confidential. I understand that many participants with a variety of medical/psychological difficulties can successfully participate in overnight camps, but it is my responsibility to make the Camp Koinonia staff aware of my child’s medical history. I acknowledge and understand that failure to truthfully and accurately disclose the required information in this form could result in serious harm to fellow participants and my child. I understand the rigorous nature of the camp. I understand that professional medical attention could be several hours away. I understand that I will be held responsible for the cost of an ambulance if my child requires one. I understand the importance of this form and have answered all statements fully and truthfully. I understand that if I am at all uncertain about my child’s ability to participate in this trip it is my obligation to consult my personal physician.