DSTX Medical Consent Statement

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Consent Statement

I consent to      (Participant’s Name) (hereinafter “participant”) participating in RYLA. The participant has permission to engage in all prescribed activities, except as noted above. It is also understood that all rules and regulations for this event will be enforced and any violation by the participant will result in the participant needing to leave RYLA which could include a call to a parent/guardian to request pick-up of the participant. In consideration of participation in this event, I agree (or if participant is under 18, legal guardian agrees on behalf of the participant) to fully and forever release, discharge, indemnify and hold harmless Rotary Club of Corpus Christi, Rotary District 5930, any sponsoring Rotary clubs, and Camp Zephyr, their agents, servants and employees, successors, insurers, assigns, and all other persons, firms or corporations who might be liable, from any and all claims, demands, damages, charges, costs rights or causes of action of whatever nature, present or future, whether the same be known, anticipated or unanticipated, resulting from or arising out of participation in this event. The participant (or legal guardian) also hereby authorizes any medical treatment required by the participant while in attendance at this event. Described above are any special medical or other needs required by the participant, and if necessary event personnel will be notified of any other special needs or information required.

(If Participant is under the age of 18, a parent or legal guardian will need to sign)
Signing Parent/Guardian Full Name:  
Relationship to Participant:  

Date Signed:


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Signature Certificate
Document name: DSTX Medical Consent Statement
lock iconUnique Document ID: d8bd43458b91eb84595e6d3c10b23575d6783112
Timestamp Audit
February 28, 2023 3:16 pm CDTDSTX Medical Consent Statement Uploaded by Bridget Markwood - admin@leadernu.com IP