2025-2026 RKDC Annual Waiver & Release Form

Both parents must be listed; use N/A if not applicable.

House number, street name, street type. (1234 Example St.)

House number, street name, street type. (1234 Example St.)
[Or, write 'Same' if shared with Parent/Guardian #1]

[Or, write 'Same' if shared with Parent/Guardian #1]

[Or, write 'Same' if shared with Parent/Guardian #1]

You may choose all that fit. If something does not apply when prompted, please use N/A.

If child is allergic to milk, please indicate an acceptable alternative.

Administrative procedures vary among medical personnel and medical facilities with regard to provision of medical care for a child in the absence of a parent or guardian. The exact procedure required by the physician or hospital to be used in emergencies should be verified in advance. In case of an accident or an emergency situation, I authorize a staff member of Refuge to notify emergency personnel and the above-named physician for such emergency treatment and measures as are deemed necessary for the safety and protection of my child(ren) at any expense.

/S/ represents an S-Signature used to serve as my signature (E.G. /S/ Jane Doe)

I give my permission for the above-named child to watch both G and/or PG rated movies during the Refuge Summer Camp program. Movie titles will be posted in advance on the Brightwheel App. If you do not approve of the movie being watched, you have the option, with 24 hours' notice, to move your child to another classroom for their movie.

In consideration of the acceptance of my application for entry into the above program/event, I use my initials to hereby waive, release, and discharge any and all claims for damages for death, personal injury, or property damage which I, or my child, may have, or which hereafter accrue to me or my child, against Refuge Church and all Refuge Staff, as a result of my and/or my child's participation in the event. I further understand that accidents and injuries can arise out of the event; knowing the risks, nevertheless, I hereby agree to assume those risks and to release and to hold harmless all of the persons or entities mentioned above. My signature releases Refuge Church and all Refuge Staff from any and all liability and/or obligation to me and/or my child(ren) for the use of such documentation. I understand that Refuge Staff has adopted concussion-related education, awareness, and protocol.

I authorize Camp staff to:

I understand there may be drop off, pick up, and screening policies and procedures for camp attendance. Refuge policies and procedures may shift, as well. I agree to abide by these standards as they develop and contact the program supervisor if I have questions or concerns.

I grant permission to Refuge Summer Camp, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child, myself, and members of my family while at Refuge Summer Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium. I hereby release Refuge Summer Camp and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or evaluation with or without my name for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child's rights, and my family's rights to any and all compensation stemming from the use of these materials.

If any property damage and/or theft results from an intentional act that my child/guardian commits, I understand that I will be held responsible and will be billed accordingly, including for material(s) and labor costs where applicable. Such acts may also be grounds for the child’s dismissal from our program, with no refund being issued.

I have received and read the 2024 Refuge Summer Camp policies and I understand and agree to abide by them. I understand that unless the entire summer camp fee is paid at least two weeks in advance, all fees will be automatically deducted from my checking or savings account through the Brightwheel App payment agreement on the Friday of the week before my child is scheduled to attend. If payment is not made on Friday, I understand my child may not attend the following Monday/week. I understand that this is the only form of payment accepted by Refuge Summer Camp, if I have not paid in full in advance. If the payment is not payable due to insufficient funds, my account will be assessed a $25.00 fine and my financial institution may also assess my account with a fee. I am aware there is a $25 registration fee, if my child is not fully registered, including my financials set up in Brightwheel, my child may not attend.

/S/ Signature (E.G. /S/ Jane Doe)

Due to supplies being purchased and teachers scheduled for the days you sign your Camper up; we do not offer "swapping" of days. With two weeks' notice, and a $25 rescheduling fee, you may ask to move or cancel scheduled dates.
We do not offer refunds. Failure to attend is not grounds for a refund. If you are not satisfied with the program, please contact the Camp Supervisor or the Refuge office.
In the case of an unforeseeable situation, our Director and/or Board may consider a refund if requested in writing. If the refund is approved, please allow up to 10 days for processing. Refunds will be subject to a $10 processing fee.
A full refund will be given if Refuge Summer Camp is cancelled by Refuge.

/S/ Signature (E.G. /S/ Jane Doe)

If your Camper's financial obligation will be covered by Family Resource and Referral, have you already been pre-approved? Your Camper will not be added to our roster until we receive confirmation from Family Resource and Referral.

MONDAY HOLIDAY

CLOSED FRIDAY JULY 4

CAMP ENDS 8/1

PAYMENT LINK: https://square.link/u/lFU6lk5b