Form b-mossRehab Camp Independence 2016-Release Form applicant name: dates: Sunday, June 19, 2016 to Saturday, June 25, 2016 photograph and statement release

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Form B-MossRehab Camp Independence 2016-Release Form
APPLICANT NAME: _________________________________________________

DATES: Sunday, June 19, 2016 to Saturday, June 25, 2016

I hereby give permission to Albert Einstein Healthcare Network, of which MossRehab is a subsidiary, to publish my photograph, audiotape, videotape and to use my name, without reservation of any kind, in any media for educational and public relations purposes. I also authorize Albert Einstein Healthcare Network to use statements made by me. Neither photograph, audiotape, videotape nor statements need be submitted for my review. I understand that Albert Einstein Healthcare Network and its Corporate Marketing and Communications Department, and any other medium of communications (including newspaper, magazine, television, radio, pamphlet, brochure, web site, social media, etc.) may use my photograph, audiotape, videotape and/or my statement without any liability on the part of Albert Einstein Healthcare Network, its subsidiaries, agents or employees. I also understand that there is no payment due me as a result of these permission grants. I intend to be legally bound by this document for a period of five years from the date below.


I hereby acknowledge ultimate responsibility for payment of medical treatment if required, during the week at Camp Independence. In order to assist with processing insurance forms, a front and back copy of my current insurance card is attached and a front and back copy of my current prescription card is attached.


I hereby grant permission to the physician designated by MossRehab or his authorized representative to furnish or arrange for the furnishing of such hospital and medical care as might be required during the period of time I am vacationing at Camp Independence. This medical care shall include examinations and treatment if necessary. This permission is conditioned upon the understanding that in the event of serious illness, or in the event of a need of hospital services and/or major surgery, all reasonable effort will be made to contact my parents, guardian, or other person I have designated for emergency reason. Failure in such efforts, however, shall not prevent the provision of emergency treatment necessary for your best life and health interest.


I hereby give permission to go to Camp Independence. In consideration of this acceptance for going to Camp, I/We hereby waive and release any claim or cause of action which may accrue against the MossRehab, Variety Club Camp and Developmental Center, and any employee or volunteer worker of either, arising out of any injury to the person or property of such person named above during his or her stay in the Camp, in transit to and from the said Camp, or during any vacation week activity. All liability is assumed by the person or persons signing this consent form.

SIGNATURE: ____________________________________________ DATE: ______________
If you are not 21 or older, a parental or guardian’s signature must also be obtained, approving the above consent form.

PARENT/GUARDIAN: ______________________________________ DATE: ______________

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