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Authorization Form for Media/Marketing Materials

Must be com pleted for ALL CAMPERS.
Cor Jesu produces marketing/informational brochures, ads and newsletters. Signing this form
authorizes the school to photograph or videotape your child(ren) and use the photographs
or tape in publications and marketing materials or feature stories. The marketing materials
may be part of the CJ website and social media posts.
o Permission is granted for:
o Permission is not granted for: CAMPER’S NAME (PLEASE PRINT)

PARENT OR GUARDIAN PRINTED NAME

PARENT OR GUARDIAN SIGNATURE DATE

Medical and Emergency Release
The following medical and emergency release must be com pleted for
ALL SPORTS CAMPERS.
I, ______________________________ (parent of ______________________________),
understand that although Cor Jesu Academy has taken precautions to provide proper use
and supervision for the Summer Camps at Cor Jesu Academy, it is impossible to guarantee
absolute safety. Also, I understand that I share the responsibility for the safety of my child/
myself during the activity and assume that responsibility. Further, I hold Cor Jesu Academy
harmless and waive any claim which may arise against Cor Jesu Academy and/or its
employees, agents, administrators.

PARENT OR GUARDIAN SIGNATURE DATE

______________________________________________ is covered by
CAMPER’S NAME (PLEASE PRINT)

INSURANCE COMPANY POLICY NUMBER

In case of accident or serious illness, I request Cor Jesu Academy to contact me. If the school
is unable to reach me, I hereby authorize the school to call the physician indicated below and
to follow his/her instructions. If it is impossible to contact the physician, the school may make
whatever arrangements seem necessary.

LOCAL PHYSICIAN’S NAME

ADDRESS

OFFICE PHONE NUMBER EXCHANGE PHONE NUMBER
ALLERGIES/OTHER CONCERNS
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