CENTER RIDGE OUTPOST INSURANCE & CONSENT WAIVERS 2026

Please fill this out for your camper. While you will have a chance to review the information prior to submitting, you will not be able to save and resume later. You will be emailed a copy of the information provided. Check your SPAM/Junk mail if you do not see the email within 5 minutes.

CAMP SESSION ATTENDING

CAMP SESSION ATTENDING Week 1 Week 2 Week 3 Week 4
CAMPER NAME CAMPER NAME First Middle Last
CAMPER BIRTHDATE CAMPER BIRTHDATE / MM / DD YYYY
CAMPER AGE
CAMPER GENDER
Last 4 digits of SSN
CAMPER RACE

This is for reporting purposes only.
Custody Status

Custody Status Parent Guardian Other Other
PARENT/ GUARDIAN'S NAME PARENT/ GUARDIAN'S NAME First Last
PARENT/ GUARDIAN'S CELL PHONE NUMBER PARENT/ GUARDIAN'S CELL PHONE NUMBER - ### - ### ####

NOT THE CAMPER'S PHONE NUMBER.
EMAlL

THIS IS HOW WE WILL CONTACT YOU. PLEASE NO CAMPER EMAIL
EMERGENCY CONTACT NAME EMERGENCY CONTACT NAME First Last
EMERGENCY CONTACT RELATIONSHIP
EMERGENCY CONTACT EMERGENCY CONTACT - ### - ### ####
INSURANCE INFORMATION OF THE CAMPER
Medicare #
Medicaid #
Insurance Company Name:
Policy #
Group #
Policy Holder's Name:
Name of Family Doctor:
Family Doctor Phone # Family Doctor Phone # - ### - ### ####
Hospital of Choice:
Please attach copies of insurance coverage card.
My signature below is evidence and verification that I agree to accept all the financial obligation of the healthcare services that my camper or I may receive beyond the amount my insurance listed above will cover. I understand that I am responsible for all expenses if I don't have insurance.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
CAMPER'S MEDICAL INFORMATION
Are camper's immunizations up-to-date?

Are camper's immunizations up-to-date? Yes No
Has camper had any recent illnesses or hospitalization in the last 5 years?

Has camper had any recent illnesses or hospitalization in the last 5 years? Yes No
If yes, please explain.
CENTER RIDGE OUTPOST WAIVERS

MEDICAL CARE

My signature below authorizes the nurse, camp medic, or authorized representatives to furnish or arrange for the furnishing of such hospital and medical care the camper might require during such time as he/she is a camper at the Center Ridge Outpost. This medical care shall include, but not be limited to, examinations, treatment, injections, anesthesia, surgery, and other procedures, etc... I understand that I shall be notified as soon as possible. Failure in such efforts shall not prevent the provision of emergency treatment necessary for the best interests of the life and health of the camper.

The nurses, staff and counselors of The Center Ridge Outpost are comprised almost solely of volunteers and/or parents of children diagnosed with autism spectrum disorders. Each is providing their time and services free with no expectation of compensation. Therefore, in the case of an emergency, first aid guidelines will be followed; and if the need necessitates, campers, counselors and/or staff will be transported to the nearest hospital by ambulance or other approved means. Every safety precaution is taken to make each camper’s camp experience enjoyable and safe.

I understand and agree that my child will receive first aid treatment by camp personnel, and if necessary, will be transported to an emergency medical facility to receive further treatment. I also understand that I will be notified promptly if such an event occurs. I release The Center Ridge Outpost nurses, counselors, staff and/or Board of Directors of TEAAM of all legal and/or financial responsibilities of events and/or treatment that might occur during camp that may result in injury to my child.

HOLD HARMLESS

For and in consideration of The Center Ridge Outpost receiving the herein named camper in the camp, and in consideration of the same, and any services which might be performed for the camper, the undersigned, as natural guardian of said camper, for and on behalf of the camp or the undersigned individual, hereby releases, acquits, covenants to hold harmless and indemnify The Center Ridge Outpost, TEAAM, its staff and volunteers and all other persons, firms and corporations associated with them, from all claims, damages, their heirs, executors, administrators, and legal representatives and assigns, arising out of any of the above procedures.

PHOTO RELEASE

The undersigned further grants permission for said camper to be photographed, with such pictures and names to be used in public relations and fund-raising efforts to promote programs of TEAAM. Said pictures will not be shared other than for the purposes of promoting TEAAM programs or fulfilling grant obligations. Though names may be shared from time to time, TEAAM's general policy is not to identify participants by name. The Mississippi Council on Developmental Disabilities (MSCDD) often provides TEAAM with grant money. In this case, photos, videos, and other image capturing processes are shared with the MSCDD.

TRANSPORTATION

I understand that Campers are responsible for their own transportaion to and from camp.

STATEMENT OF EXCLUSION

I understand that if the Parent or Guardian does not sign a release for specialized activities, the Camper will not be able to participate.
I understand and accept the information and waivers provided in this form.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
You will be able to review a copy of the information prior to submission. A copy of the data entered will be sent to the email provided once submitted. Check your SPAM/Junk email if you do not see the email within 5 minutes.
PHOTO RELEASE

I give permission for said camper to be photographed, with such pictures and names to be used in public relations and fund-raising efforts to promote programs of TEAAM. Said pictures will not be shared other than for the purposes of promoting TEAAM programs or fulfilling grant obligations. Though names may be shared from time to time, TEAAM's general policy is not to identify participants by name. The Mississippi Council on Developmental Disabilities (MSCDD) often provides TEAAM with grant money. In this case, photos, videos, and other image capturing processes are shared with the MSCDD.

PHOTO RELEASE I give permission for said camper to be photographed, with such pictures and names to be used in public relations and fund-raising efforts to promote programs of TEAAM. Said pictures will not be shared other than for the purposes of promoting TEAAM programs or fulfilling grant obligations. Though names may be shared from time to time, TEAAM's general policy is not to identify participants by name. The Mississippi Council on Developmental Disabilities (MSCDD) often provides TEAAM with grant money. In this case, photos, videos, and other image capturing processes are shared with the MSCDD. Yes No

CENTER RIDGE OUTPOST INSURANCE & CONSENT WAIVERS 2026

CENTER RIDGE OUTPOST INSURANCE & CONSENT WAIVERS 2026

INSURANCE INFORMATION OF THE CAMPER

CAMPER'S MEDICAL INFORMATION

You will be able to review a copy of the information prior to submission. A copy of the data entered will be sent to the email provided once submitted. Check your SPAM/Junk email if you do not see the email within 5 minutes.