Thank you!

Name of Participant *

First Name

Last Name

Participant Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Please select program attending *

Netta Day Camp- Week 1 (June 14-18)

Netta Day Camp- Week 2 (June 21-25)

Netta Day Camp- Week 3 (June 28-July 2)

Netta Day Camp- Week 4 (July 5-9)

Netta Day Camp- Week 5 (July 12-16)

Netta Day Camp- Week 6 (July 19-23)

Netta Day Camp- Week 7 (July 26-30)

Middle School Conference- Session 1 (June 17-20)

Middle School Conference- Session 2 (June 22-25)

Middle School Conference- Session 3 (July 8-11)

Middle School Conference- Session 4 (July 13-16)

Called Together (Aug. 2-5)

Bible Conference/Church Music Conference (July 25-31)

Massanetta Employee

Policy Holder *

First Name

Last Name

Policy Holder Date of Birth *

MM

DD

YYYY

I voluntarily consent and authorize Diligent Urgent Care, LLC (DUC) to conduct collection, testing, and analysis for the purposes of a COVID-19 diagnostic test. I acknowledge and understand that my COVID-19 diagnostic test will require the collection of an appropriate sample by my healthcare provider through a nasopharyngeal swab, oral swab, or other recommended collection procedures. I understand that there are risks and benefits associated with undergoing a diagnostic test for COVID-19 and there may be a potential for false positive or false negative test results. I assume complete and full responsibility to take appropriate action with regards to my test results. Should I have questions or concerns regarding my results, or a worsening of my condition, I shall promptly seek advice and treatment from an appropriate medical provider. *

Yes, I give my consent

No, I do not consent

I authorize MASSANETTA SPRINGS CAMP to release my medical forms and insurance information to Diligent Urgent Care, LLC. I authorize DILIGENT URGENT CARE, LLC to release (verbal or written) confidential medical information to any person or entity that is related in any way to this visit, in accordance with national and state laws that apply. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. (Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a)) I agree, with respect to my COVID-19 test, to authorize the test results to be provided to Massanetta Springs Camp. *

Yes, I give my consent

No, I do not consent