be greater Buck Creek Camp $ Winter Camp Feb 27-Mar 1 Tubing - Zipline - Friends Speaker - Snow - Games Worship (forms due ASAP)

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Melinda Greer
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1 2015 Winter Camp Feb 27-Mar 1 Buck Creek Camp $119 (forms due ASAP) (scholarships available) be greater Tubing - Zipline - Friends Speaker - Snow - Games Worship payment accepted online - forms online - bethanystudents.com

2 Bethany Baptist Church Consent for Medical Treatment; Hold Harmless for Travel Winter Retreat - February 27-March 1, 2015; Buck Creek Camp Note to Parent/Guardian/Guest: Bethany Baptist Church wants this 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: 1. Medical history 2. Medical insurance information 3. Consent for medical treatment 1. Attendee: Birth date: / / 2. Whereas (my child), wishes to attend a trip with Bethany Baptist Church student ministries group which will be traveling to and staying near Mt Baker, Wa, and WHEREAS, certain circumstances may occur resulting in (my child s) need for medical/ dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment; THEREFORE, in consideration of permission from Bethany Baptist Church for (my child/ myself) to participate in said trip, 4. I,, being of legal age, authorize Bethany Baptist Church, or any designated agent of Bethany Baptist Church, to act on (my child s/my) behalf should I be unable to do so and to consent to all medical/dental care and treatment, including but not limited to diagnostic test, x-ray, examination, anesthesia, surgery, or other procedures which Bethany Baptist Church deems necessary for (my child s/my) medical well-being for the duration of the trip. This consent is given in advance of any specific diagnosis, treatment, surgery, or hospital care required and to the administration of any over the counter medications including but not limited to Tylenol, Advil, allergy medications, and is given to provide authorization and specific, consent for medical/dental treatment and care in (my child s/my) behalf. Any consent by Bethany Baptist Church shall have the same force and effect as if I had personally given the consent. 5. I certify I have personal health insurance, including foreign countries, with no territorial limitation, for the providing of medical services to (my child/me) which will provide coverage for (my child/me) during the duration of said trip. I understand that Bethany Baptist Church provides no health plan. Insurance Company Policy # Insurance Company Phone Number I hereby release Bethany Baptist Church, it s agents, servants, employees, and assign for any and all damages, liabilities or costs resulting from the authorizing of medical treatment on (my child s/my) behalf under the terms of this consent. I further hold Bethany Baptist Church harmless and agree to indemnify Bethany Baptist Church of any and all costs, damages, or expenses incurred by Bethany Baptist Church as a result of any claim or action filed by any party alleging damages incurred as a result of any medical treatment provided or authorization for treatment provided. I understand that this release and indemnification releases treatment for the conduct of Bethany Baptist Church and its agents, servants, employees, or assigns even if such conduct is negligent

3 Parent or Guardian Information (for applicant s under 18) Name Phone # Address City State ZIP In case of emergency, and we cannot contact you, who should we contact: Name Phone # Address Alt. Phone # City State ZIP Relationship to applicant: Health History (Give approximate dates) Disease Allergies (Date not needed) Frequent Ear Infections Chicken Pox Hay Fever Heart Defect/Disease Measles Food Diabetes German Measles Insect Stings Bleeding/Clotting Disorder Mumps Penicillin Hypertension Other Drugs (Please list below) Mononucleosis Asthma Convulsions Other (specify) Please complete the following questions: Are you currently taking any prescribed medications? Yes No If yes, please specify medication and dosage: Are you currently using any non-prescription drugs on a regular basis, such as antihistamines or sleeping aids? Yes No If yes, please specify: Are you currently under a physician s care for any illness? Yes No If yes, please explain: Are there any medical conditions or physical limitations we should know about for this trip? Yes No If yes, please explain: Do you have any allergies? Yes No If yes, please specify:

4 Conduct Agreement The rules and regulations of Bethany Baptist Church Student Ministries are designed to enhance the experience, protect each participant, and maintain a high level of integrity. The enforcement of all procedures and regulations are the responsibility of the Bethany Baptist Church staff, which includes adult volunteers serving as trip leaders. We reserve the right to send any student home due to improper conduct. The use or possession of alcohol or illegal drugs will result in immediate dismissal. A student and/or his/her family are responsible for any costs involved in sending the student home. 6. X Date: Student Signature 7. X Date: Parent Or Guardian s Signature Student Contact Information and Camp Registration: Name: Phone: Shirt Size: School Grade: DOB: 1 Person you would like to room with:

5 C,IMP BERACHAH MINISTRIES INpOnvpo CONsn,NI/RpTEASE op LTaSILITY Dear Participant, You are going to join us on a program involving the use of the Adventure Course. We are requesting that all participants sign an Informed ConsenVRelease of Liability form. The following describes the responsibilities of Camp Berachah, as well as the responsibilities of any consenting participant : 1. There will be strenuous physical activity involved. Although all individuals in average health will be able to comfortably participate, it shall be each individual's responsibility to be sure she/he is healthy.l 2. Some activities will involve more risk2 than one engages in during normal daily routines. Each individual will be informed of the risk involved, and of the behaviors and skills necessary to safely complete the activity. The participant will choose whether or not to engage in the activity, and assume the risk on any potential physical or emotional injury or disability. Personal responsibility is key to safety. 3. Camp Berachah requires that every participant have accident/health insurance coverage. In addition, certain medicallhealth infomation must be known by the instructor(s) facilitating the program, so they are prepared to respond appropriately ifthe need arises. 4. No alcoholic beverage, tobacco, or use of any drugs is permitted on the course. Prescription medication and any existing injury must be reported before the program. the undersigned, agree to participate in the Camp Berachah program using the Adventure Course. I have completed the medicallhealthreview on the back of this sheet. I acknowledge that I have been advised that I can decline to participate in all or part of the activities occurring during this program. I hereby release Camp Berachah and its contractors from any and all liability with relationship to participation on _(aate). This release includes the transportation to and from the site of the activities, as well as the activities themselves. Signature Date Parent signature (if child is under 18) I The An-rerican liearl Associalion has published guidelines. u,hich are helplul" if 1ou have concems about cardiolascular stress during the ropes challcngc course parlicipation (Circulation. r,ol. 82, no. 6. Dcc pp ). Infbrmation from this rcport is summarized: "Exercise has both risks and bcncfits. N4ant,factors afl'ect risk of erercise. 'l'hree of the most imporlant are age. presence ofheart disease. and intensitl'olcxercise. Studies indicate that in the general population. risk ofsudden caldiac dcath during vigorous erercise is ver1,lou,. It is believed that the benefits ofexercise exceed the risks. and that individlrals should bc cncouragcd to exercise. provided thel'take measures to minintize risk.''. r Tn'o national sal'ct,r'studics have demonstrated ropes challenge cours:s 1o bc l5 lime safer than clril'ing an autornobile.

6 Name Home address Daytime phone Name of physician Evening phone Phone Address Name of insurance Emergency contact Group and ID number Phone Address Height Weight Sex_Age Health: Excellent Good Fair Please answer all of the questions. Poor 1. Are you aware of any medicallhealth conditions that could be aggravated by physical activity, such as: Heart disease, high blood pressure, lung disease, diabetes, asthma, seizures, pregnancy, or others? 2. Are you aware of any problems with your neck, back, shoulders, wrists, hips, ankles, knees, or other that could be aggravated by physical activity? 3. Have you had any major injury, illness, or surgery lately? NoD 4. Do you have any allergies? 5. Do you take any medications? NoE 6. Do you have any minor or major disability? Do you use an orthopedic device?

Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM

Prairies to Peaks Iron Horse Rail Summer Camp REGISTRATION AND HEALTH FORM Section 1 Basic Contact Information Campers Name: _ Nickname:_ Birth date / / Gender: Male Female T-shirt size: Adult / Youth