Dear Parents and Students, On the weekend of March 27-29, 2015 we are inviting all of our 10th - 12th graders to Raleigh, NC for the 25th annual Campus Harvest Conference with the theme, "Change the Campus, Change the World." We are trusting God for 55 students and leaders to attend this year! Our RUSH Leadership Team will chaperone and be involved the entire weekend. We will caravan with the area Every Nation Campus team, but we will have our own charter bus, separate hotel rooms, and streamlined schedule for our RUSH team. The tentative schedule is as follows : Friday, March 27th Depart from Nashville - 1am Breakfast on road - 7am Arrive in Raleigh, NC- 1pm Lunch at Mall Food Court- 1pm Pizza for Dinner - 6pm Session 1-7pm Saturday, March 28th Free Breakfast in Hotel - 8am Session 2-9am Session 3-1pm Free time-4:30pm- 6:30pm Session 4-7pm Sunday, March 29th Free Breakfast in Hotel- 8am Depart for Nashville at 9am Arrive in Nashville at approximately 5pm If you plan to attend Campus Harvest, the cost is $185.00. There is a non-refundable deposit of $55.00 that is due by Wednesday, February 25 th. Visit campusharvest.org for more information. If you have questions concerning Campus Harvest email Megan.Mandel@bethelworld.org. Passionate for the Next Generation of Christ-followers, Pastors Mike Cantrell and Ernie Kruger
DAMAGE RESPONSIBILITY AGREEMENT CAMPUS HARVEST RALEIGH, NC (MARCH 27 29) I take full financial responsibility for damages incurred by myself or with a group of individuals at King s Park Church property during Campus Harvest. I agree to pay for those damages upon return. Signature: CONSENT FOR RELEASE TO MEDIA I hereby give my full consent to RUSH Youth Movement to record my participation in any programs or events associated with Campus Harvest. Further, I hereby transfer and assign to Bethel World Outreach Center the exclusive right to use and to authorize others to use said images, video, and audio recordings for promotional and educational use or resource sale in the future. I understand that my image may be used, but my name or personal information will never be shared publicly without additional, separate consent. Signature: Bethel s agreement with all the above property owners is that we commit to pay for any and all damages that are incurred in any cabin, condominium, house or meeting space that we inhabit. In order to best negotiate the responsibility, it is necessary that our participants understand that any charges incurred due to damage caused by an individual (or group of individuals) will be passed on to that party and will be expected to be paid. MEDICAL RELEASE FORM All activities operated by Bethel World Outreach Center (the Church ), under the supervision of the staff and volunteers of Bethel World Outreach Center, require the completion and acceptance of a medical release prior to participation. Name: Date : I apply to Bethel World Outreach Center to participate in the activity or activities described and indicated above ( Activity ). I acknowledge and agree to, and represent, the following for myself, in consideration of the opportunity to be provided by the Church (contingent upon its agreement to my participation). Acknowledgment of Risks. I acknowledge that participating in the Activity involves risks of serious damage and harm to persons and property, and even death, and I assume those risks, including risks arising from acts or failures to act of the Church. Information Relied on by Church. I am the participant who is signing this document. I am in
good health and of sound mind. If necessary, I have discussed or will discuss with my physician my participation in the Activity, and I have received or will receive any vaccination or other recommend prerequisite medical treatment my physician deems necessary. I will participate in the Activity only if I have received my physician s approval, if I deem it necessary, and believe that I am able to participate without harm. I acknowledge that the Church will not assess or approve my fitness for participation. I am under no force or duress of any kind to be compelled to participate in the Activity or my signing of this document. Release. THIS DOCUMENT IS INTENDED TO ABSOLVE THE CHURCH OF ANY LIABILITY TO ME THAT IS RELATED TO MY PARTICIPATION IN THE ACTIVITY. Accordingly, I hereby release the Church from, waive, and will never sue the Church for, any damage (whether damage to or loss of property, finances, life, body, mind, or emotions), cost, suit, demand, claim, or other liability, that arises or is alleged to arise from or in connection with the student s participation in the Activity. Such liability includes any liability that arises or is alleged to arise from the Church s negligence (but not its willful and wanton misconduct). Such liability also includes any liability that arises or is alleged to arise from claims for contribution by another that I have sued or from whom I have received compensation. Medical Permission. I give my permission to be treated for illness or injury sustained while participating in the Activity, including by the administration of emergency anesthesia or surgery; and authorize the adult leaders of the Activity to act on my behalf in ordering such treatment. Definitions. (a) References to me, my, and I shall include and bind me, my spouse, and any insurer, heir, estate, legal representative, executor, administrator, successor, or assign of me. (b) Participation or participating in the activity includes planning and preparing for, traveling to, and traveling from, as well as participating in, the Activity. (c) The Church includes (i) its affiliates, and institutions cooperating in the Activity; (ii) the trustees, elders, deacons, officers, employees, volunteers, and agents of the Church or such affiliate or institution; and (iii) the spouses, insurers, heirs, estates, legal representatives, executors, administrators, successors, estates, and assigns of any of the foregoing. Brief Medical History In the event of an emergency, the most accurate and updated information will be extremely helpful for us in providing you with the best care. List all Medical Conditions and any current Medication regimens: List all known Allergies:
Emergency Contact Name: Relationship: Phone: INSURANCE INFORMATION Your Full Name: Date Of Birth: / / Cell Phone: Home Phone: Alternate Phone: Home Address: City, Zip Insurance Information Insurance Carrier: Insurance Carrier s Phone Number: Policy Number/Group Number: Policy Holder s Name: Date of Birth: / / Prescription Coverage (if applicable) Insurance Carrier: Insurance Carrier s Phone Number: Policy Number/Group Number: (if different from above) Policy Holder s Name: Date of Birth: / / Student Signature: Parent/Guardian Signature: