Genesis Golf / Genesis Golf4Kids / Genesis Golf Trips
200 Bailey Drive, Ste. 104, Stewartstown, PA 17363
www.GenesisGolf4Kids.com
717-993-3028
CAMPER PERMISSION FORM FOR PARENTS
Name of Camper (Please Print):
Address:
City:
State:
Zip:
Parent/Guardian Phone:
Age of Child:
Date of Birth:
Academic Grade (Fall 2016):
Shirt Size:
Golf Clubs: Y/N
We have youth sizes available only
Golf Experience thus far, if any:
Motivators: ________________________________________________________________________________
3 Positive Personality Traits:
1. _________________________________________________________
(Ex: kind, honest, thoughtful, etc.)
2. _________________________________________________________
3. _________________________________________________________
Something your child wants us to know about him/ her: _____________________________________________________
Sports & Other Activities (i.e. karate, soccer, etc.): __________________________________________________________
ASSUMPTION OF RISK & RELEASE OF LIABILITY AGREEMENT BY PARENTS & CHILD (“AGREEMENT”)
Functions and Activities
It is my understanding that participating in the programs and recreational and other activities is a privilege. Prior to my participation in
such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to
activity-related accidents. By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of
withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child
participating in the various golf and game activities, whether such risks are known or unknown to me at this time.
Release of Liability
I, the undersigned, do hereby understand and acknowledge that the recreational sports and activities offered carry inherent risks that could
lead to injury. I hereby expressly and voluntarily accept and assume all risks involved within the golf camp experience offered by Genesis
Golf4Kids I have read and agree to follow all rules or ask for an explanation of all rules and policies provided. I understand that I may ask
for and will receive an explanation of any rules and codes of conduct at anytime. I also acknowledge that I have read the Codes of Conduct/
Policies & Procedures and accept them. I accept for use, as is, any and all Genesis Golf4Kids services.
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Parent or Guardian Acceptance, Initial Here ___________x
I further agree that I will indemnify and hold harmless Genesis Golf4Kids from any liability, and injury of any kind that it may incur as the
result of any injury caused by myself, by any member of my family or by any person for whom I am signing this Agreement, even if I
contend that such injuries are the result of any negligence or any other improper conduct for which a release is not contrary to public
policy, on the part of Genesis Golf4Kids (Genesis Golf Trips, Genesis Golf, and Genesis Publishing, LLC, its owners, operators, managers,
agents and employees) herein referred to at Genesis Golf4Kids. I further agree that I will indemnify and hold harmless Genesis Golf4Kids
from any liability, injury or cost of any kind that it may incur as the result of any injury caused by myself, by any member of my family or by
any person for whom I am signing this Agreement, even if I contend that such injuries are the result of any negligence or any other
improper conduct for which a release is not contrary to public policy, on the part of Genesis Golf4Kids.
Notwithstanding the foregoing, that if I sue Genesis Golf4Kids, I agree that I will only bring suit, whether on my own behalf or on behalf of a
family member, in the Court of Common Pleas of York County or in the United States District Court for the Middle District of Pennsylvania. I
understand and agree that this Agreement is governed by the laws of Pennsylvania. I further agree that if any part of this Agreement is
determined to be unenforceable, all other parts shall be given full force and effect. Furthermore, by signing this waiver I consent to the use
of my image, likeness, actions and statements in connection with any live or recorded audio or photograph while participating in any
recreational sports and activities offered by Genesis Golf4Kids.
First Aid and Emergency Medical Treatment
I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a
result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and
secure any needed medical attention or treatment for the child names above including hospitalization, if in the agent’s opinion such need
arises, in doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending
physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the
medical treatment. I give permission for the camp Coach or other camp staff to give over-the counter medications as needed. I give
permission to transport the child named above to a medical treatment center in a non-emergency vehicle in a medical emergency situation.
Medical Concerns
1. Does the camper have any known physical reasons which might interfere with his/her participation in strenuous or our golf
instruction and game activity? If so, please explain
2.
Does the camper have any FOOD allergies that we need to be aware of for snack break? Explain
Known Allergies:
Health Insurance
Insurance Company:
Policy Number:
Family Physician:
Phone Number:
Phone Number:
Emergency Contact
Name of Persons and telephone numbers to call in case of emergency: (must provide at least (2) names)
Name/Relationship:
Cell:
Work:
Name/Relationship:
Cell:
Work:
Name/Relationship:
Cell:
Work:
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Parent or Guardian Acceptance, Initial Here ___________x
Authorized Pickup
Name of ALL Persons Authorized to Drop Off and Pickup Child Including Self and Other Parents/Guardians
NO ONE WILL BE ALLOWED TO SIGN A CHILD IN OR OUT OR TAKE HIM/HER OFF THE PREMISES WITHOUT PERMISSION!
Please remember that photo identification will be required until we get to know you and your child.
NAME:
PHONE:
CITY:
RELATIONSHIP:
I represent that I am the parent/guardian of
, who is under 18 years of age. I have read the
above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate
in the activities of Genesis Golf4Kids, including any special event/activities described above. In consideration for allowing the participation
of the child in these activities, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the
child and agree that it shall be binding upon me, my family, heirs, legal representatives, successors and assigns.
Participant Name (Please Print): ____________________________________________________
Parent or Guardian Signature:___________________________________Date:_______________
Parent or Guardian Name (Please Print) ________________________________________________________
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Parent or Guardian Acceptance, Initial Here ___________x