(a) Informed Consent, Indemnity and Hold Harmless Agreement 

I have voluntarily elected to allow the minor child identified below to use the facilities and equipment at Camp Awosting located at 296 West Street, Morris, CT 06763 (“Camp Awosting Facility”). In consideration for being allowed to use said facilities and equipment, and any other services provided by Camp Awosting, the JoeAbate Charitable Foundation or its employees or agents at said location acknowledge and agree as follows:

I acknowledge and agree that this Agreement covers and is intended to release and provide other benefits, legal protections, and consideration to Camp Awosting, the JoeAbate Charitable Foundation and their respective and collective agents, owners, officers, managers, shareholders, affiliates, volunteers, participants, employees, and all other persons or entities acting in any capacity on their respective or collective behalf.

I acknowledge and agree that the use of camp facilities, the lake and the other equipment at Camp Awosting is inherently and obviously dangerous. I understand that participation in CTHeart Camp (a JoeAbate Charitable Foundation program) activities involves a certain degree of risk. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activities. These activities can be physically, mentally, and emotionally demanding. I also understand that participation in these activities is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. 

In case of an emergency involving me or my child, I understand that every effort will be made to contact the individual listed as the emergency contact person. In the event that this person cannot be reached, permission is hereby given to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for me or my child. Medical providers are authorized to disclose protected health information to the adult in charge, camp medical staff, camp management, and/or any physician or health care provider involved in providing medical care to the participant. Protected Health Information/Confidential Health Information (PHI/CHI) under the Standards for Privacy of Individually Identifiable Health Information,45C.F.R. §§160.103,164.501,etc. seq., as amended from time to time, includes examination findings, test results, and treatment provided for purposes of medical evaluation of the participant, follow-up and communication with the participant’s parents or guardian, and/or determination of the participant’s ability to continue in the program activities.

I have carefully considered the risk involved and give consent for myself and/or my child to participate in these activities. I approve the sharing of the information on this form with the JoeAbate Charitable Foundation and Camp Awosting volunteers and professionals who need to know of medical situations that might require special consideration for the safe conducting of CTHeart Camp activities.

I understand and acknowledge that the participation in the activities planned at the Camp involves inherent risk of possibly serious injury to my child.  I agree to indemnify agents, officers and all employees of the JoeAbate Charitable Foundation, Camp Awosting, Counselors, Junior Counselors, volunteers, related parties or other organizations associated with the activity (hereinafter “Releasees”), for any costs or expenses arising out of my child’s participation in the activities including the cost of any medical care given to my child or any damages, expenses or fees incurred in any claim arising as a result of any damages or injuries caused by my child in the course of his or her participation in the Camp.  I agree to release Releasees from any and all claims, specifically but not limited to any and all claims for injuries to my child, as a result of the participation in the camp.  

I further agree to indemnify and save harmless Releasees from any and all claims and demands, whether for injuries to my child, loss of life or damage to property, occurring due to participation in the camp, excepting however for those damages caused by the gross negligence or intentional act of Releasees.

I release the JoeAbate Charitable Foundation, Camp Awosting, agents, employees and/or officers, Counselors, Junior Counselors, volunteers, related parties or other organizations associated with the activity, from any and all claims or liability arising out of this participation without restrictions.

(b) Privacy Notice

I understand that the staff at CTHeart Camp believes my child’s health information is private and respect the need for protection of that privacy, and also feel that sharing the health information in the context of CTHeart Camp is important for enhanced communication and safety of campers.  Therefore, I grant permission to share medical information with staff and medical personnel participating with CTHeart Camp regarding my child named below.

(c) Photo and Media Consent

I hereby assign and grant to the JoeAbate Charitable Foundation, the local council and Camp Awosting the right and permission to use and publish the photographs/film/videotapes/electronic representations and/or sound recordings made of me or my child at all camp activities, and I hereby release the JoeAbate Charitable Foundation, Camp Awosting, the local council, the activity coordinators, and all employees, volunteers, related parties, or other organizations associated with the activity from any and all liability from such use and publication.

I hereby authorize the reproduction, sale, copyright, exhibit, broadcast, electronic storage, and/or distribution of said photographs/ film/videotapes/electronic representations and/or sound recordings without limitation at the discretion of the JoeAbate Charitable Foundation, and Camp Awosting, and I specifically waive any right to any compensation I may have for any of the foregoing.

By signing this release and waiver of copyright and other usage rights below, I intend to be legally bound hereby, for myself and my heirs, executors and administrators.  In consideration of the opportunity for participating at CTHeart Camp, a program of the JoeAbate Charitable Foundation, held at Camp Awosting, I acknowledge and agree that the JoeAbate Charitable Foundation (including and without limitation, all affiliates) have the right to use photographs, videotapes or other recordings or images of me/my child in program activities in public relations and promotional materials including, but not limited to videotapes, pamphlets, posters, brochures and electronic media such as internet websites.  I further acknowledge that the JoeAbate Charitable Foundation shall have the rights of copyright in and to such photographs, videotapes, and other recordings and may exploit said copyright fully. I release and waive all rights and interest in and to such materials.