2013 P ROVINCIAL Y OUTH E VENT

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Derick Garrett
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PROVINCE III OF THE EPISCOPAL CHURCH THE EPISCOPAL DIOCESE OF AND WEST VIRGINIA PROUDLY ANNOUNCE THE 2013 P ROVINCIAL Y OUTH E VENT MARCH 1 3, 2013 AT NORTH BAY ADVENTURE CAMP IN NORTH EAST, MARYLAND

1 PROVINCE III OF THE EPISCOPAL CHURCH THE EPISCOPAL DIOCESE OF AND WEST VIRGINIA PROUDLY ANNOUNCE THE 2013 P ROVINCIAL Y OUTH E VENT MARCH 1 3, 2013 AT NORTH BAY ADVENTURE CAMP IN NORTH EAST, MARYLAND Province III of the Episcopal Church will be hosting a youth event for high students. The theme for the weekend is Be: Be Still, Believe and Belong. Registration Deadline February 15 Registration Cost: $180* The Diocese fully supports this event and will therefore provide a 1/3rd scholarship to all participants and ask participants and their home churches to each provide 1/3rd ($60) as well. FOR QUESTIONS AND MORE INFORMATION CONTACT : Stephen Day Jason Beschinski sday@wvdiocese.org jbeschinski@wvdiocese.org (304) (304)

2 M ORE ABOUT PYE 2013 The event will be held at the exciting NorthBay Adventure Camp, which is located on the Chesapeake Bay between Baltimore, Maryland and Philadelphia, Pennsylvania. This exciting facility offers the following options, many of which are covered by the registration fee: Indoor and Outdoor Rockwalls Low Ropes Course Bouldering Disc Golf Giant Swing Hiking Zip Line and more High Ropes Course You can get more info about NorthBay Adventure at the following web address Don t Forget 2 pairs of tennis or hiking shoes Sweater/Sweatshirt A warm coat A Hat, gloves, and scarf Clothing you can layer Several changes of clothing Several pairs of socks Packing List Pillow, fitted sheet & Sleeping bag Towel & toiletries Medications Water Bottle Flashlight Sunglasses Don t Bring MP3 Players or ipods Tablets or ipads Gaming Platforms Snack Food Tobacco products Drugs Alcohol NorthBay Adventure Camp is located at 11 Horseshoe Point Lane, North East, Maryland, That is 420 miles from Charleston, West Virginia, so the Diocese will be providing transportation from certain key points for this trip. Our goal is to arrive at NorthBay around 8 PM on Friday, March 1. This likely means that some participants will have to miss part of school that day. Our tentative gathering points will be Charleston and Morgantown, West Virginia and then Hagerstown, Maryland. Below is a tentative schedule for our stops on our way to NorthBay. - Charleston, WV Noon - Morgantown, WV 2:45 PM - Hagerstown, MD w/ dinner 5:30 PM - NorthBay 8:30 PM More information about the return trip will be provided later. There are two forms that need to be completed: A diocesan registration form (2 pages) A NorthBay medical and release form for their records (1 page)

3 Diocese of Fellowship Episcopal Youth West Virginia EYF Provincial Youth EvEnt 2013 March 1 3, 2013 in north East, MarYland sponsored by the EPiscoPal diocese of WEst virginia 1 of 3 ParticiPant information Name: Home Church: Mailing Address: Phone: School and Grade: Parent/Guardian with legal custody: Cell#: Emergency Contact (If parent/guardian is unreachable. Please list at least one): Name: Relation: Phone: Name: Relation: Phone: Living in community: In order to ensure the emotional, physical, and spiritual safety of everyone participating in diocesan youth events, it is important that we live up to our baptismal covenant. With God s help, we will seek and serve Christ in all persons, loving our neighbors as ourselves; we will strive for justice and peace among all peoples, respecting the dignity of every human being. 1. Approach new experiences and activities with an open mind, and participate fully in planned events (work details, worship, small group activities, plenary sessions, meals, etc). 2. Respect and care for the facility that is being used. 3. Respect the feelings and dignity of all persons present. 4. Refrain from any and all sexual behavior. 5. Refrain from entering the sleeping areas used by members of the opposite sex. 6. Remain on the premises and be present at all scheduled activities. (including pocket-knives), or weapons of any type. Failure to follow the above agreement will be handled immediately by the Leadership Team and/or the Diocesan Youth home immediately at one s own expense and without refund. Participant: I have read and agree to follow the above agreement. Signature Date Parent/Guardian: I have read and support my child in following the above agreement. Signature Date Mail completed forms and checks to: Episcopal Diocese of West Virginia, PO Box 5400, Charleston, WV 25361

4 MEdical information 2 of 3 Please list all allergies and other medical conditions the Diocesan Youth Coordinator(s) should be aware of (food and medical allergies, asthma, recent illness, chronic or current health concerns, etc): Please list all medications (prescription and over-the-counter) taken by the participant (attach additional sheet, if necessary). All medication(s) must be turned in to the Diocesan Youth Coordinator(s) at the time of registration: Medication Time(s) Given Dosage insurance information Carrier: Policy: Group ID: over the counter medication The following non-prescription medications may be on hand to treat minor ailments. Cross out those that should not be given. (Note: medications will be administered according to the dosage instructions on the label): Pepto-Bismol Midol Tylenol Advil Waiver of LiabiLity and medical release I, the parent/guardian of, give permission for his/her full participation in events associated with PYE 2013 operated by the Episcopal Diocese of West Virginia. I give permission for my child to travel by church van or private vehicle while on Episcopal Youth Fellowship (EYF) events sponsored by the Episcopal photographs or video footage of my child to be used by The Diocese of West Virginia for promotional purposes (brochures, on diocesan websites, promotional videos, Facebook, YouTube, etc). I give my permission for my child s contact information to be included on a roster that will be distributed to other participants. I also give permission to the leaders of this program to non-surgical medical care as needed. I agree to hold the Diocese of West Virginia and any associated agencies and persons harmless and waive any claims for payment for accident, injury, disability or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activity. Signature of Parent/Guardian: Date: (or adult participant s own signature) Mail completed forms and checks to: Episcopal Diocese of West Virginia, PO Box 5400, Charleston, WV 25361

List any allergies to medications: NORTHBAY GUEST HEALTH INFORMATION FORM Note to Guest: NorthBay wants the camp experience to be a safe and healthy one.

5 List any allergies to medications: NORTHBAY GUEST HEALTH INFORMATION FORM Note to Guest: NorthBay wants the camp experience to be a safe and healthy one. However in the event of an accident or illness, it is important that we have the following information. Group Name Guest Information Last Name: First Name: Middle: Birth Date: Sex: Male/Female Cell Phone: Home Address: Home Phone: Emergency Contact: Relationship: Cell Phone: Home Address: Home Phone: My Insurance Company: Policy Number: Not Currently Insured NorthBay reserves the right to subrogation if it is later determined that personal medical insurance was in place. List any major medical conditions: HEALTH HISTORY 3 of 3 RELEASE OF LIABILITY AND ASSUMPTIONS OF RISK At NorthBay, health, safety, and supervision are paramount. The approach to safety and risk management is accompanied with competence, judgment, and purposeful sound programming. Guest safety and well-being is everyone s concern. As a policy of NorthBay, we require that a Release of Liability Form be signed as a requirement to attend camp. I represent that I desire to attend a camp and participate in activities sponsored by NorthBay, LLC ( NorthBay ). In consideration for NorthBay permitting the Guest to attend the camp and participate in the activities, I have agreed to execute this Release of Liability and Assumption of Risks (the Release ). I assert the information given on this health form is complete and accurate to the best of my knowledge. I acknowledge that participating in some of the activities sponsored by NorthBay, including canoeing, kayaking, boating, water skiing, hiking, swimming, snorkeling, tubing, fishing, rock climbing, zip line, sport activities, nature and acclimatization activities, and using the ropes course, involve certain inherent risks, including the risk of serious personal injury. I agree I shall assume all such risks, including the risk of serious personal injury. I agree I shall assume all such risks, as well as any other risks involved in any activities sponsored by or involving NorthBay. I also agree to release and discharge NorthBay and all of its employees, agents, and representatives, as well as all other persons, corporations, or other entities that might have any liability to or me (the "Released Parties"), from and against any and all damages, actions, claims, and liabilities, whether known or unknown, anticipated or unanticipated, suspected or unsuspected, relating to or arising from me attending camp or being involved in any activity, occurrence, or event connected to Northbay. This Release is intended to release and discharge the Released Parties from all damages, actions, claims, and liabilities arising from or related to the negligence of the Released Parties. I further agree to indemnify, hold harmless, and defend NorthBay from and against any loss, damage, liability and expense, including costs and attorneys fees, incurred by NorthBay that is related to or arise from me attending camp or being involved in any activity, occurrence, or event connected in any way to NorthBay. I hereby grant permission to NorthBay the right to use, reproduce, and/or distribute photographs, films, video-tapes, and sound recordings of me, without compensation or approval rights, for use in materials created for purposes of promoting the activities of NorthBay. The laws of the State of Maryland shall govern the rights and obligations of the parties to this Release and the interpretation, construction, and enforceability thereof. I agree that any lawsuit brought against any Released Party shall be brought solely in the Circuit Court for Baltimore County, Maryland. I hereby voluntarily waive any right I may have to a trial by jury in any action, proceeding or litigation involving any Released Party. I further agree to pay any attorney s fees incurred by NorthBay if I attempt to contest the validity of this Release. In the event I cannot be reached in an emergency when I am under camp supervision, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and/or order injections, anesthesia, or surgery for myself. If something were to happen to me a doctor selected by the camp may treat me for any injury/illness. THIS RELEASE IS A BINDING LEGAL CONTRACT, PLEASE READ IT CAREFULLY BEFORE SIGNING. Signature of adult guest: Date: If the guest is under 18 years of age: Signature of parent/guardian: Date:

Diocesan Youth Ski Trip January 16-18, 2015

Diocesan Youth Ski Trip January 16-18, 2015 Participant s first & last name: Date of birth: Age (as of January 12, 2015): Grade: Gender: Sweatshirt size: (All sizes adult; please circle one) S M L XL Church: