Page 11 - CJA High School Summer Camps

Authorization Form for Media/Marketing Materials

Must be completed 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 CJA website and social media posts.
Permission is granted for:
Permission is not granted for:
CAMPER’S NAME (PLEASE PRINT)

PARENT OR GUARDIAN PRINTED NAME

PARENT OR GUARDIAN SIGNATURE DATE

Medical and Emergency Releases
The following medical and emergency release must be completed
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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