Immunization Exemption

Immunization Exemption Form

Because our camp program has a potential for communicable diseases, we recommend that program participants are appropriately immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, smallpox, pertussis (whooping cough), and diphtheria. This being said, we recognize that some individuals may not be fully immunized for reasons that are biophysical (e.g., the individual is allergic to a serum component) or of personal choice (e.g., faith belief). This form is intended to capture information about individuals who are not fully immunized.

Who should complete this form?

A custodial parent/legal guardian of an underage camper who is not fully immunized.
An adult participant, including a staff member, who is not fully immunized.

I request that…

Name of Individual

First

Last

Enrolled in session

Reason for exemption

To the best of my knowledge and belief, the person named above is and has been in normal good health and is free from all communicable or contagious disease. Should this participant show symptoms that reasonably indicate the presence of a communicable or contagious disease, I agree that a physical examination may be performed. I also agree that if any such disease is found, we – the named individual and his/her family – will comply with the quarantine or isolation procedures required of the camp as directed by the state’s Department of Health.

It is further understood that, should a communicable disease emergency arise, I will be notified. However, in the event that I cannot be contacted, the camp’s administrator(s) and healthcare staff may take the temporary measures they deem necessary to protect the health status of this participant.

I release and forever discharge Lake Ann Camp and each and every one of its officers, directors, employees, agents, insurers, affiliates, attorneys, or any other person or persons associated with any or all of them or any variation in the name of any or all of them who might be liable (the Released Parties) from all causes of action, suits, claims, demands, or any other damages or costs associated with actions taken by the Released Parties relative to the health, sickness and treatment of

Name of Individual

First

Last

Individual Name of

I further understand and acknowledge that I make this release in full accord and satisfaction of and in compromise of any current or future disputed or alleged claims or causes of action relative to the health, sickness and treatment of…

Name of Individual

First

Last

…against the Released Parties.

I represent and acknowledge that I have read and understand this agreement and release and warrant that all statements made herein are true to the best of my knowledge. I further warrant and acknowledge that I am of legal age, legally competent to execute this agreement and release, and accept full responsibility therefore.

Signature

Clear Signature

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code