Rocky Bottom Retreat and Conference Center of The Blind

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Children's Camp 2020 Application
June 7 - 13, 2020

Your Vision. Your Future


























Informed Consent and Acknowledgement


Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature.


I hereby give my approval for my child’s participation in any and all activities prepared by Children’s Camp for the Blind during the selected camp. In exchange for the acceptance of said child’s candidacy by Children’s Camp for the Blind, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Children’s Camp for the Blind and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.


In case of injury to said child, I hereby waive all claims against Children’s Camp for the Blind including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.



Page 2 - Health Form

The health form is kept confidential and used by our health services staff (or emergency medical personnel). Every camper needs a completed health form to participate in any summer camp programs. Please fill out this form as completely as possible. Thank you!































Please check where applicable.


Please record the month and year of immunizations. If you do not know the dates or whether camper has had certain immunizations, simply leave blank.

















Please know that we value your privacy. Health History information is available only to the camp health staff. The more information you provide, the better we can do our job. Thanks! Has the camper have a history of or is prone to any of the following: (Please check all that apply).













Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature.
In consideration for my son's/daughter's participation I agree to indemnify National Federation of the Blind (NFB), National Federation of the Blind of South Carolina, (NFBSC), NFBSC dba Rocky Bottom Camp of the Blind for and all legal liability in the event that any accident, injury, loss of property or any other circumstance or incident occurs during or as a result of participation in the trip.
This Release of liability includes accident, injury, loss or damages to the student, as well as, to other individuals or property which may result from the students participation in the event. I hereby release and agree to hold harmless; NFB, NFBSC, and Rocky Bottom Camp of the Blind, It's Officials, Agents and Employees from any claims arising out of my son's / daughter's participation in the event.
CONSENT FOR MEDICAL CONSENT AND TREATMENT AND ADMINISTRATION OF MEDICATION
I hereby warrant that to the best of my knowledge my child is in good health and I assume all responsibility for the health of my child. I give Rocky Bottom Camp of the Blind permissions for emergency and other medical treatment to include the administration of the above prescription and not prescription medications.



Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature.
Rocky Bottom Retreat and Conference Center of the Blind Summer Children's Camp and Volunteers are Designated By The Abbreviation “RBRC” Throughout This Entire Form

• I (we) hereby authorize RBRC to take my (our) child to the before named physician or facility for medical treatment in the event of an emergency in which neither parent can be reached.


• I (we) hereby give permission for my (our) child to attend and participate in activities sponsored by RBRC.


• I (we) hereby authorize RBRC to transport my (our) child to or from camp and/or any other camp related and sponsored activities and events.


• I (we) hereby authorize RBRC to include my (our) child in supervised water activities.


• I (we) hereby authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the medical practice act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at the said hospital.


• I (we) hereby agree to provide all necessary medications for my (our) child with detailed dosage instructions and authorize it to be dispensed to my (our) child by the appointed nurse of RBRC.


• I (we) do hereby authorize any licensed physician or medical treatment center to treat my (our) child in the case of emergency in which the before named physician cannot respond.


• The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.


• Should it be necessary for my (our) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.


• I (we) hereby release, forever discharge and agree to hold harmless RBRC and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the undersigned adult and the child-participant that occur while said child is participating in any trip or activity with RBRC.


• Furthermore, I (we) [and on behalf of my (our) child-participant if under the age of 18 years] hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein.


• Further authorization and permission is hereby given to RBRC to furnish any necessary transportation, food, and lodging for this participant.


• The undersigned further hereby agrees to hold harmless and indemnify RBRC, its directors, employees, and agents for any liability sustained by RBRC as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.


• The medical consent and liability waiver provisions hereof shall remain in full force throughout 2020 and in effect until written notice of revocation or withdrawal is received by RBRC at its office.


•  It is the responsibility of the parent or guardian to notify RBRC of any changes in medical condition, guardianship, address or phone change.




Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature.

I take full responsibility for my child during all 2020 Rocky Bottom Retreat and Conference Center of the Blind Summer Children's Camp Events.


In the event of any personal or property damage done by my child, I understand that I am morally, and financially responsible.

This includes:


• Negligent physical harm or injury inflicted to another individual by my child.


• Property damage to any and all objects done by my child.


• Transportation expense home for my child due to early dismissal from said event for use or possession of alcohol, tobacco, illegal drugs, inhalants, and pornographic materials.


• Transportation expense home for my child due to their inability to gain personal control over any actions that may cause injury to oneself or another.


• Transportation expense home for my child due to their causing excessive and persistent disruption to the entire group during said event.

All dismissal decisions are at the discretion of the Children's Camp Director. In the event that damage is caused by more than one child, equal responsibility is taken by all involved.


When responsibility for damage is not claimed, all those closely related will share in responsibility and expense (example: room damage unaccounted for = all room members share responsibility).


All final decisions are the responsibility of the Children's Camp Director after discussion with all volunteer adults involved. It is never our desire to send a student home and we will do all we can to work with you, the parent, in impacting your child positively. When any serious problem arises, you will receive a phone call so that the matter can be discussed and the proper action taken.




Please read the following statement carefully, then acknowledge that you have read and approved it by providing the information requested at the bottom of the page. Please note that an esignature is the electronic equivalent of a hand-written signature.
I hereby grant permission for my child to be video taped and/or photographed while participating in programs and activities of Rocky Bottom Retreat and Conference Center of the Blind Summer Children's Camp. It is my understanding that video taping and photographs will be used for educational, training and promotional purposes only.


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