I hereby authorize the Director, Doctor, or Nurse of Camp Dream Street to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed by the Arizona Medical Board, or to consent to an x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to the minor by a dentist licensed by the Arizona State Board of Dental Examiners. This authorization shall be effective whether such diagnosis, treatment or care is rendered at the office of said physician or dentist, at a hospital, at Camp Dream Street, or elsewhere, and shall remain effective while I am or my said child/ward is enroute to or from or involved or participating in any program or activity of Camp Dream Street, unless earlier revoked by me in writing and delivered to the Director.
I hereby acknowledge that for the proper functioning of Camp Dream Street, a unique summer camp exclusively for individuals with serious health issues, it is necessary that the doctor I nursing I therapist staff at the camp be able to discuss the Camper/Counselor's health issues with the non-medical counseling and other staff so that the staff is able to assist with providing a camp experience which is sensitive to and consistent with the Camper/Counselor's health issues, limitations, and requirements. While the camp staff does not provide health care, they need to understand the health conditions to assure that activities are tailored to the needs, abilities and limitations of those attending the camp.
I further acknowledges that discussions between the doctor and nurses and the non-medical staff may be filmed for purposes of promoting interest in Camp Dream Street by the general public and by potential donors. The undersigned acknowledges that such discussions may include medical record information pertaining to the Camper/Counselor. I further understand that such film may be submitted to news organizations and other commercial broadcast facilities for human interest coverage of the Camp, its campers and staff or used at Camp Dream Street fundraising functions or to supplement a Camp Dream Street speech to hospitals, businesses, groups or organizations.
In full consideration of the foregoing, the undersigned hereby authorizes the medical staff of Camp Dream Street, including without limitation, its doctors, nurses and physical therapists, as applicable, to disclose the undersigned's full medical record information to the non-medical staff of Camp Dream Street for the purposes stated above and the undersigned further authorizes that such medical information discussions between the medical staff and non-medical staff at Camp Dream Street may be filmed for the purposes stated above.
On my own behalf and on behalf of my child/ward, I hereby expressly release, discharge and hold harmless Camp Dream Street, the Dream Street Foundation and Canyon Ranch and their respective agents, employees, officers, directors and representatives, from any liability or responsibility relating to or arising from any damage, loss, or injury sustained by Camper/ Counselor while traveling to or from Camp Dream Street, while attending Camp Dream Street, while participating in any activities at Camp Dream Street or any trips or other activities sponsored by the Dream Street Foundation, or while staying in any accommodations provided or arranged by Camp Dream Street or by the Dream Street Foundation, other than any such liability or responsibility which may arise as a result of their gross negligence or willful misconduct. Without limiting the generality of the foregoing, this release includes within its scope any loss, damage or injury sustained as a result of any ordinary negligence, whether active or passive on the part of Camp Dream Street, the Dream Street Foundation. or any of their officers, agents, employees or representatives.
The forgoing release is to be construed in accordance with the laws of the State of Arizona. It is intended to release claims which are known and which are as yet unknown. Accordingly. I hereby waive, on my own behalf and on behalf of my child/ ward, the provisions of any applicable statute which provides in substance:
"A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor."
I have read and understood the medical history and information form, and the information I have given is true and correct.
