Epinephrine administration agreement – Camp KidsTown

Release and Wavier of Liability and Indemnity

The Participant and Parent/Legal Guardian agree to release and waive all claims and hereby indemnify and hold harmless the Corporation of Camp KidsTown, its volunteers and other participants for any and all liability for any property damage or personal injury resulting from the administration of epinephrine. The Participant and Parent/Legal Guardian hereby further agree that Camp KidsTown, its volunteers and other participants shall not be liable, either directly or indirectly, for any claims, or any damages, costs and expenses respecting any act done in good faith, including, but not limited to personal injury, death, property damage or loss in the administration of epinephrine, whether or not such injury, damage or loss occurred as a result of any negligence, negligent misrepresentation or breach of statutory duty and/or breach of contract on the part of Camp KidsTown, its volunteers and other participants, unless damages are the result of gross negligence on the part of Camp KidsTown, its volunteers and other participants.

Assumption of Risks

The administration of epinephrine involves various risks, dangers and hazards which the Participant is required to assume. The Participant and Parent/Legal Guardian hereby freely accept and fully assume all such risks, dangers and hazards and the possibility of personal injury, death, property or loss resulting there from.

Consent to Medical Treatment

The participant and Guardian agree to hereby give permission to have the Camp KidsTown, its volunteers and other participants arrange for any emergency medical care including hospitalization/transportation, if necessary, to the administration of such emergency medical treatment as may be deemed necessary in the circumstances. The Participant and Parent/Legal Guardian agrees to pay all costs associated with medical care and transportation.

Parent/Guardian informed authorization and release for the assistance in the administering of an EpiPen

I/we have requested that an EpiPen be administered in the event of an anaphylaxis emergency. I/we understand that this service will be provided by a person without medical or nursing training. I/we understand that Specialty program/facility staff will only assist in the administration (Camper’s hand on EpiPen; staff hand over Camper’s hand) of an EpiPen. I/we agree to provide Camp KidsTown staff with a written and up-to-date medical statement whenever there is a change in the physician’s instructions with respect to medication. I/we also agree that the camper will carry the Epipen on their person at all times. Should the camper arrive at the program without their EpiPen, they will be removed from program activities until a Parent/Guardian can arrive on site with the EpiPen or pick up the child.

Parents/legal guardians have completed the appropriate forms for anaphylaxis emergencies and have provided two (2) doses of current medication.