Currituck County Youth Safety Camp

Child Name:

Child Information

Parent/Guardian Contact Information

Parent/Guardian #1

Parent/Guardian #2

Emergency Contact Information – Alternate Pickup/Release

Emergency Contact

Child Name:

Medical Release Information

In case of an emergency, contact (with Contact #1 being the highest priority):

Contact #1:

Contact #2:

Contact #3:

Child Name:

Terms of Agreement

Photograph/Video/Audio Release:

I hereby give permission for my child to be photographed, video recorded, or audio recorded anytime during Currituck County Youth Public Safety Camp gatherings. I understand that the photographs, videos, and audio obtained may be used for promotional purposes, social media, print and/or TV media, et cetera., and I do not expect compensation. I agree that all photographs, videos, and audio recordings are property of Currituck County Department of Fire-EMS, however, use permissions may be obtained from the Department.

Transportation Release:

I hereby give permission for the transportation of my child to and from any Currituck County Youth Public Safety Camp activities by modes of transportation agreed upon by the Department of Fire-EMS and its affiliates, including by, but not limited to fire apparatus, EMS apparatus and law enforcement vehicles.

Firefighting and Emergency Medical Services Activities:

I hereby give permission for my child to participate in firefighting and emergency medical services activities including, but not limited to:

• Use of a fire extinguisher to extinguish a propane fueled controlled fire
• Use of fire hose
• Climbing of a ground ladder (not to exceed 24’ in total height)
• Perform cardiopulmonary resuscitation (CPR) on manikins
• Perform physical activities while performing firefighter job functions
• Practice home escape techniques in a low-visibility environment

Release of Confidential Information:

I hereby give permission to the Currituck County Department of Fire-EMS representatives, employees, agents, and public safety partners to access and/or disclose my child’s personal and health information in the event of an emergency.

Movie Release:

I hereby give permission to the respective representatives, employees, agents, and public safety partners of the Currituck County Department of Fire-EMS to show my child movies and shows with G, PG and PG-13 ratings.

Permission for Medical Treatment:

I authorize and grant authority to Currituck County Department of Fire-EMS and/or its public safety partners to obtain emergency or necessary medical care (up to and including advanced life support treatment and transport) for the juvenile named on Page 1 while said child is attending and/or participating in the Currituck County Youth Public Safety Camp. Parents or guardians listed will be contacted in the event of injury or illness of the minor child. The granting of this authority is effective from and including all dates on which the Currituck County Public SafetyCamp gathers, meets, et cetera.

Sickness/Illness:

I understand that in the event my child becomes sick or ill, I, or an approved pickup person, will pick up my child up within one hour from the current location of the Currituck County Youth Public Safety Camp meeting location.

Alternate Pickup/Release:

I hereby give the Currituck County Department of Fire-EMS, its representatives, employees, agents, and public safety partners to release my child, in the absence of a parent or guardian, to the emergency contact/pickup person as is listed on Page 1.

Identification Required for Release:

I understand that I, or the authorized alternative pickup person, will need to show proof of identification (valid Driver’s License or state issued ID Card) to the Camp staff member responsible for student release prior to him/her releasing my child to the said person.

Release of Liability:

In consideration for attendance by the juvenile named on Page 1 of this form for the Currituck County Youth Public Safety Camp, I authorize and execute this release of liability, on behalf of the aforementioned minor child/juvenile, covenant and agree to release from liability and hold harmless the County of Currituck, Currituck County Department of Fire-EMS, and their respective representatives, employees, agents, volunteers, officials and public safety partners from any loss, damage or harm including death or personal injury, arising out of the acts, omissions or conduct of whatever nature as it pertains to the operation of the Currituck County Youth Public Safety Camp.

Assumption of Risk:

It is anticipated that juvenile participants attending the Currituck County Youth Public Safety Camp ("Camp") will engage in light to moderate physical activity from time to time, which may include intramural sports. It is understood and acknowledged that there is a risk of injury involved in any athletic, firefighting or emergency medical services activity. Juveniles attending this Camp will be under the general supervision and direction of Currituck County Department of Fire-EMS, and other Currituck County Public Safety staff during the Camp's activities. However, it is understood that Currituck County Department of Fire-EMS cannot eliminate the risk or injury or illness due to juvenile participation in any phase of the camp activities. Injuries may and sometimes do occur from participation in any physical activity. I freely, knowingly, and willingly acknowledge, accept, and assume the risk of injury that might occur from participating in the activities of the Currituck County Youth Public Safety Camp.