(parent/guardian name) hereby give permission for my child,
, (child’s name) to attend Southern Grace Hospices event- Camp Grace. I
understand the camp’s goal is to help facilitate the bereavement process for my family and provide support
for us in expressing feelings of grief.
Health History Acknowledgment
To my knowledge, I have completed my child’s health history and all information provided is accurate and
complete. The child described is a healthy person who is physically, mentally, socially, and emotionally
capable of a camp experience. I hereby understand that no participant shall be brought to camp if known to
have any contagious conditions (influenza, pink eye, lice, etc.) My child has permission to fully engage in all
camp activities, except as noted, subject to the policies, rules, and regulations of Camp Grace.
I give permission for my child to be photographed and/or videotaped during Camp Grace. I understand that
these photographs and/or videotapes will remain the property of Southern Grace Hospice, and they may
now or in the future be used for promotional and/or educational purposes.
I hereby authorize a Registered Nurse of Southern Grace Hospice, to administer any
first aid and/or medical treatment which is deemed necessary in the case of sickness or injury of the above-
named child; and hereby agree to indemnify and hold the staff and/or Southern Grace Hospice harmless
from any and all claims for any injury which could be sustained by said child during the Camp Grace event.
Southern Grace Hospice will make every effort to contact me in the case of an emergency. I give my
permission for Southern Grace Hospice and its medical staff to arrange for any necessary medical treatment
to myself/my children, including onsite and offsite emergency care. I accept responsibility for the costs of all
such medical treatment.
In the event I, or AUTHORIZED emergency contacts, cannot be reached in an emergency, I hereby give
permission to the Camp Coordinator or their designee, to act as the parent/caregiver concerning the health
and welfare of the participant.
Hold Harmless Agreement
In consideration of the above-named child being granted permission to attend Camp Grace
I, for myself and on behalf of my child(ren), release and discharge Southern Grace Hospice, as well as its
directors, administrators, agents, employees, volunteers, and officers, from any and all claims, demands,
actions and judgments whatsoever of every name and nature, both in law and equity which I or my child(ren)
ever had, now have, or may have against Southern Grace Hospice for personal injuries, either physical or
emotional, known or unknown, and injury to property, real or personal, sustained by me or my child(ren)’s
person or property during our attendance at Camp Grace, whether the injury is caused by negligence or any
In the event my child requires transportation to and/or from the event, I understand that said transportation
will be provided by Southern Grace Hospice employees and/or volunteers via private vehicle. I hereby release
Southern Grace Hospice, as well as its directors, administrators, agents, employees, volunteers, and officers
from any and all liability or damages for any and all injuries caused by negligence or any other fault of my
child while traveling to this activity via private transportation.
I have read this form carefully and have had all questions answered before signing this legal document and
giving the consents and waivers contained in it. I acknowledge that this is a legal document and I will be
bound by my agreement to its terms. I represent to Southern Grace Hospice that I have the legal authority to
provide consent on behalf of my child.