Policies for families and children at Pinewoods

Parent and Guardian Responsibility Form and Medical Care Authorization Form

A Statement of Responsibility form for each camper under age 18 must be signed by the child's parent (and the appointed guardian, if applicable). This form should be downloaded, printed out, completed, and sent to the FAC office before arrival at camp. Forms can be scanned and emailed to the FAC office (fac@facone.org) or mailed to FAC at 10 Franklin Street, Stoneham MA 02180-1862.

Download a printable PDF version of this form.

I. For children attending camp with their parent or parents:

I/we, __________________________________________ , parent(s) of

______________________________ (child’s full name) accept full responsibility for my/our child named above while in attendance at Pinewoods Camp during

________________________________________ (name of session). I/we have read and agree to comply with the Pinewoods Camp, Inc. Rules for Campers under 18, and waive all claims, demands, causes of action, and suits for personal injury, property damage, and other liability that may occur to my/our child named above while in attendance at Pinewoods Camp.

signature of parent __________________________________ date _________


signature of other parent _____________________________ date _________

II. For children attending camp with a guardian (complete both sections):

I/we, __________________________________________, parent(s) of

_____________________________ (child’s full name) accept full responsibility for my/our child named above while in attendance at Pinewoods Camp during

______________________________________ (name of session). I/we have read and agree to comply with the Pinewoods Camp, Inc. Rules for Campers under 18, and waive all claims, demands, causes of action, and suits for personal injury, property damage, and other liability that may occur to my/our child named above while in attendance at Pinewoods Camp. In addition,

_____________________________________ (name of guardian over 18) has permission to authorize emergency medical treatment, as necessary, for the child named above.

signature of parent __________________________________ date _________

 

I, ______________________________________ (name of guardian over 18), accept full responsibility for

________________________________________ (child’s full name) while in attendance at Pinewoods Camp during

________________________________________ (name of session). I have read and agree to comply with the Pinewoods Camp, Inc. Rules for Campers under 18, and waive all claims, demands, causes of action, and suits for personal injury, property damage, and other liability that may occur to the child named above while in attendance at Pinewoods Camp.

signature of guardian ________________________________ date _________

This form must be provided by FAC to Pinewoods Camp, Inc., before arrival at camp in order for your child to attend.

Pinewoods Camp Inc. Parent resp. form.01 JS rev.04.30.04