To provide you with services through the Autism Society of Minnesota (AuSM) Camps, AuSM may need to use and disclose health-related information about you and/or your child.
I AUTHORIZE AuSM to use and disclose my/my child’s name and disability information as follows: my/my child’s contact information, information about my/my child’s physical health, mental health or other services, and payment for services.
I hereby agree, for myself and on behalf of my child and/or legal ward, heirs, administrators, personal representatives, assigns, and/or guests, if any, to the following:
The camper/guardian has read and understands all the information in this application and acknowledges that a wide variety of activities are conducted at Autism Society of Minnesota (AuSM) camps and gives permission for the camper named above to participate in these activities assuming all ordinary risks normally inherent to the nature of the activities. It is also understood that the camper may be transported and be out of camp while on a field trip or camping trip.
That in consideration of AuSM allowing use of camp programs at various locations and participation in its activities, under the terms set forth herein, I agree to hold harmless, release and discharge AuSM, its owners, agents, employees, personnel, sponsors, officers, directors, representatives, assigns, members, affiliated organizations, insurers, and others acting on its behalf (hereinafter collectively referred to as “ASSOCIATES”), of and from all claims, demands, causes of action and legal liability, whether the same be known or unknown, anticipated or unanticipated, due to AuSM and/or its ASSOCIATES’ ordinary negligence; and I do further agree that, except in the event of AuSM and/or its ASSOCIATES’ gross negligence and willful and wanton misconduct, I shall not bring any claims, demands, legal actions and causes of action, against AuSM and/or its ASSOCIATES as stated above in this clause, for any economic and/or non-economic losses due to bodily injury, death, property damage sustained by me and/or my minor children and/or legal wards, if any, in relation to the premises and/or operations of AuSM.
That if I engage in any physical activity or use of any camp facility on the premises, I agree to do so at my own risk and assume the risk of any and all injury and/or damage while engaging in any physical activity or use of any camp facility on the premises. My assumption of risk includes, but is not limited to, my use of any facility items (see Camp Waiver/Release form). I agree to assume this risk in my participation in any activity, class, program, service, instruction or AuSM sponsored event. I agree that I am VOLUNTARILY participating in camp activities and using camp facilities and premises and assume all risk of injury, harm, damage, or loss to me and my property that might result, including, without limitation, any loss or theft of any personal property. In the event of illness or injury to my child, I authorize any official representative of AuSM a to administer and/or secure medical treatment as deemed necessary by said representative.
This Agreement shall be governed by the laws of the State of Minnesota. If any of its provisions are held to be invalid or unenforceable by a court of competent jurisdiction, such holding shall not invalidate any of the other provisions of this Agreement, it being intended that the provisions of this Agreement are severable.
I attest that the camper is fit and prepared to use camp facilities and participate in camp activities. I ACKNOWLEDGE THAT I HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY AND EXPRESS ASSUMPTION OF RISK. I AM AWARE AND AGREE THAT BY SIGNING THIS WAIVER AND RELEASE, I AM GIVING UP MY RIGHT TO BRING LEGAL ACTION OR ASSERT A CLAIM AGAINST Autism Society of Minnesota FOR ITS NEGLIGENCE OR FOR ANY DEFECTIVE PRODUCT ON THE CAMP PREMISES. I HAVE READ AND VOLUNTARILY SIGNED THE WAIVER AND RELEASE AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENT APART FROM THE FOREGOING WRITTEN AGREEMENT HAVE BEEN MADE.