Registration for Philly Xtreme 2014

Transcription

1 Registration for Philly Xtreme 2014 Date: Church name: Leader s name: Did you participate in Flood Philly 2013: YES NO Contact information: Name: Last First M/I Address: City: State: Zip: Phone: Cell: address: Birthdate (month/day/year) Emergency Contact: Name Number Relationship T-Shirt Size: S M L XL XXL XXXL How did you become interested in Philly Xtreme 2014? June July (circle session you re attending)

2 PERSONAL REFERENCES Adult Name Address Phone Number Pastor/ Ch. Leader Have you signed the New Life Island Release Form? (This is done yearly) Have you signed the Waiver of Liability and Indemnity? (This is done yearly) Have you signed the Statement of Faith? (This is done yearly) Have you filled out your Medical Form? (This is done yearly) Have you filled out the Child Protection Policy and Clearance Form? (This is done every 5 years) I certify that to the best of my knowledge all answers and information given on this application are true and correct. Signature Date PERMISSION FORM FOR PICTURES I,, give permission for my voice and/or image to be used for promotional and publicity purposes. Student s Signature Parent s Signature PERMISSION FORM FOR CROSSING STATE LINE I,, give permission for to cross state lines. Parent s Signature

3 Release from liability: I understand that all reasonable precautions will be taken at all times by CEF and staff during all activities. I understand the possibility of unforeseen hazards and know the inherent possibility to risk. I agree not to hold CEF, it s leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by subject of this form. Signature: Date: Signature of parent or legal guardian if volunteer is under 18 years old: Signature: Date: Personal Testimony Include verses that support your faith. (when you became a child of God)

4 MEDICAL REPORT Name Address Home Phone Date of Birth Father/Guardian s Emergency Contact Number Mother/Guardian s Emergency Contact Number PAST MEDICAL HISTORY 3. Medical and Surgical Facts A. Please list operations you have had and the year you had them. B. Please list any major accidents you have had that resulted in a health problem you have now. Explain the health problem please. C. Please list any medication you routinely take for: (Please list the actual dose amount and when you take it.) 1. Headaches 2. Upset stomach 3. Allergies List allergy to food, medication, or environmental substances.

5 All medication brought to Philly Xtreme needs to be handled through your team leader. There should be no medications with a minor. D. Do you have any physical limitations not already mentioned that would be important for the director or other personnel to know? 4. In Case of Emergency Family Physician & Phone Number Name of Insurance ID Number Group Number Employer that insurance is through Employee name that insurance is in Birthday Second contact if parents are unreachable Phone/cell IMMUNIZATIONS (Date of last immunization) Tetanus Date MMR (Measles, Mumps, Rubella) Signed PARENTAL/GUARDIAN PERMISSION I,, parent or guardian of hereby authorize the youth leader at the Child Evangelism Fellowship Philly Xtreme project to serve in loco parentis for me in giving over-the-counter medication to my son or daughter. I authorize the team leader of CEF staff to serve in loco parentis for me in taking my son or daughter to a doctor or emergency room for any urgent need with the understanding that the parent or guardian will be notified as soon as possible. Signed Date LIABILITY AND RESPONSIBILITY CLAUSE Child Evangelism Fellowship is not responsible for any medical bills incurred during any of the training, events or outreach. I understand that I, the parent or guardian, will be responsible for any medical bills for my child and will make sure all medical bills are paid for in full. Signed Date

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12 New Life Island P.O. Box 480 Frenchtown, NJ Release and Assumption of Risk Form for Adventure Programming I am aware that during the Adventure Programming, (Paintball, Tubing, Canoeing, Kayaking, Low and High Ropes), in which I am or my child is participating at New Life Island, certain risks or dangers may be present. I have and do hereby assume all of the above hazards and other related risks which may be encountered during any Adventure Programming activity, and I do hereby hold New Life Island, its agents, employees, and associates harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever which I now have or which may arise from, or in connection with my participation in any Adventure Programming event. I also certify that I am or my child is physically capable of participation in the Adventure Programming at New Life Island. I hereby irrevocably consent to and authorize the use and reproduction by New Life Island, or anyone authorized by New Life Island, of any, and all images taken during the Adventure Programming activity in which I am or my child is participating without further compensation to me. All negatives, positives and digital images shall be the property of New Life Island. I agree to obey and follow all rules, regulations, and instructions of New Life Island, its agents, employees and associates. The terms hereof shall serve as a release, indemnification, and assumption of risk for my heirs, executors and administrators and for all members of my family, including any minors accompanying me. This is a legally binding document, which I have read and understand. A Parent or Legal Guardian must give permission for all persons under age 18. Participant Information: (All information must be complete) Name Age Phone Address/City/State/Zip X (Signature of Participant) X (Signature of Parent or Legal Guardian) (Date)

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14 Waiver of Liability and Idemnity Idemnity: The undersigned student and parent and or legal guardian each jointly and severally, hereby releases, waives his or her rights to recover against, and agrees to indemnity, defend and hold harmless Child Evangelism Fellowship and all its staff an parent subsidiary and related entities and its and their respective officers, directors, employees, agents, servants and insurers (hereafter jointly referred to as the indemnities ) from and for any and all claims or causes of action for any losses, damages, property loss or theft, costs, expenses (including attorney s few and opinion witness fees0, complaints, personal injury, death or other loss arising form or relating in any way to student s participation in the summer events including, without limitation to the travel, club times, lodging, games, crafts, training and wrongful acts of others that are harmful to the student or person. Waiver: The undersigned student and parent and or legal guardian each waive any and all claims that may arise against Child Evangelism Fellowship and all its operators, and all its staff an parent subsidiary and related entities and its and their respective officers, directors, employees, agents, servants and insurers as a result of or in any way related to student s participation in the directors, employees, agents, servants and insurers as a result of or in any way related to student s participation in the summer events, including without limitation to the travel, club times, lodging, games, crafts, training and wrongful acts of others that are harmful to the student or person. Including but not limited to claims alleging negligence, gross negligence, and or willful and wanton negligence. The undersigned student and parent and or legal guardian each further agree to waive the protection afforded by any statute or law in any jurisdiction the purpose, substance and or effect of which is to provide that a general release shall not extend to claims, material or otherwise, which the person giving the release does not know or suspect to exist at the time or executing the release. This means, in part that the undersigned is releasing unknown future claims. Covenant not to Sue; The undersigned student and parent and or legal guardian each jointly promise and agree that he or she will not sue Child Evangelism Fellowship and all its staff an parent subsidiary and related entities and its and their respective officers, directors, employees, agents, servants and insurers for any damages, losses, claims, causes of action, suits, demands, costs, complaints, including those resulting from the undersigned s illness, injury, and or death, released and waived in the two prodeeding paragraphs or other loss arising form or relating in any way to student s participation in the summer events including, without limitation to the travel, club times, lodging, games, crafts, training and wrongful acts of others that are harmful to the student or person. The undersigned student and parent and or legal guardian each further agrees that Child Evangelism Fellowship and any worker, staff, volunteer, or those associated with Child Evangelism Fellowship may plead this agreement as a full and complete defense to any suit brought in violation of this promise. Agreements not limited by actions of Child Evangelism Fellowship: The undersigned student s and parent s and or legal guardian s agreements and obligations under the three preceding paragraphs shall not be limited or reduced in any way because any of the losses, damages, property damage, property loss or theft, costs, complaints, personal injury, death or other loss, including those resulting from the undersigned s illness, injury, and or death, arise or result in whole or in part from the negligence of or breach of any express or implied warranty or duty of Child Evangelism Fellowship or any of its its operators, and all its staff an parent subsidiary and related entities and its and their respective officers, directors, employees, agents, servants and insurers. Final Signatures: Student Parent/legal guardian Date