Loading...

2019 Youth Winter Waiver (Lost Creek)

RELEASE; PAYMENT OF EXPENSES; MEDICAL CONSENT

 

  1. The undersigned parent(s) or legal guardian(s) (“Parent”) grants   permission for their son or daughter (“Child”) to participate in Cedar Park Assembly of God’s 2018 Youth Winter Camp (“Event”) to be held at the venue known as "Lost Creek Campground" owned and operated by Cedar Springs Camp & Conference Center,  located at 1260 Lost Creek Rd, Naches, WA 98937 and the immediate vicinity. This includes permission for transportation to and from Island Lake Camp.
  2. Parent expressly grants Cedar Park permission to transport Child to and from the Event. Parent understands and accepts that surface conditions on roads, parking lots, walkways, stairs and any other area exposed to the elements of nature are subject to the deposit, melting and freezing (and refreezing) of snow, rain, sleet, hail and ice such that walking and/or driving on such surfaces may become dangerous. Parent expressly understands assumes all risks associated with transportation.
  3. Parent expressly understands that participation in winter activities and the Event (including the sport of “Snow Sliding” in all forms), the use of snow equipment (including sleds and inner-tubes) involve risks of property damage, injury or death that no amount of care, caution instruction or expertise can eliminate. These dangers include, but are not limited to, variations in terrain and surface conditions, falls, loss of control, collisions with other individuals or with natural and man-made objects.
  4. The Parent expressly warrants that the Child is capable of withstanding the physical demands of the activities involved at the Event, including rigorous physical activities, such as, but not limited to, outdoor and indoor sports, hiking, sledding and inner-tubing. The Parent expressly warrants that the child is capable of activities that are physically demanding. Parent acknowledges that Child’s participation in any Youth Camp activity presents risks such that Parent’s Child may suffer property damage, bodily injury, or death. 
  5. Parent recognizes and acknowledges that there are certain dangers and risks of physical injury related to cold-weather activities and engaging in snow activities, including, but not limited to “inner tubing”, “snowball fights” and other potentially dangerous snow-related activities. Parent also understand that in order for the Child to be allowed engage in snow activities such as those listed above, Parent must give up rights to hold Cedar Park liable for any injury or damage which the Child may suffer as a result of these activities. Parent again voluntarily agrees to assume the full risk of any and all injuries, damages or loss, regardless of severity, that the Child may sustain during the course of the Event. 
  6. The Parent grants permission to Cedar Park and its employees and agents to seek and secure any medical attention or treatment for the Child including hospitalization, if in the agent’s opinion such need arises and Cedar Park is unable to contact the Parent.  The Parent gives consent to any licensed physician to administer drugs or medicine or to perform such medical procedures as that physician determines necessary for the relief of pain and to preserve the Child’s life or health. Parent also grants Cedar Park staff permission to administer basic first aid if the need arises. 
  7. The Parent agrees to assume the responsibility for all medical, transportation, rescue and other related expenses incurred on behalf of the Child. 
  8. The Parent releases and agrees to hold harmless, defend and indemnify Cedar Park, its directors, officers, employees and agents from and against any and all claims for personal injury (including loss of life) and all other losses or damages (except those caused entirely by the gross negligence or intentional conduct of Cedar Park Assembly) that the Child or the Parent may suffer as a result of the Child’s participation and/or enrollment at the Event. 
  9. On occasion, Cedar Park takes photographs or makes an audio or video tape recording of children involved in church activities.  Such photographs or video records may be used by staff and participants to remember the activities or participants.  In addition, such photographs and audio/visual recordings may be used in Cedar Park publications or advertising materials to let others know about Cedar Park’s ministry.  The Parent consents to the use of any such audio or visual record of the Child named above to be used, distributed, or displayed as agents of the church see fit.  This consent includes but is not limited to: photographs, videotape, and audio recordings. 

PLEASE READ CAREFULLY.  THIS DOCUMENT CONTAINS A RELEASE AND WAIVER OF LIABILITY.

 

First Child Name

First Name*

Middle Name

Last Name*

Phone*
First Child Date of Birth*
First Child Signature*
Second Child Name

First Name*

Middle Name

Last Name*
Second Child Date of Birth*
Second Child Signature*
Third Child Name

First Name*

Middle Name

Last Name*
Third Child Date of Birth*
Third Child Signature*
Fourth Child Name

First Name*

Middle Name

Last Name*
Fourth Child Date of Birth*
Fourth Child Signature*
Fifth Child Name

First Name*

Middle Name

Last Name*
Fifth Child Date of Birth*
Fifth Child Signature*
Sixth Child Name

First Name*

Middle Name

Last Name*
Sixth Child Date of Birth*
Sixth Child Signature*
Seventh Child Name

First Name*

Middle Name

Last Name*
Seventh Child Date of Birth*
Seventh Child Signature*
Eighth Child Name

First Name*

Middle Name

Last Name*
Eighth Child Date of Birth*
Eighth Child Signature*
Ninth Child Name

First Name*

Middle Name

Last Name*
Ninth Child Date of Birth*
Ninth Child Signature*
Tenth Child Name

First Name*

Middle Name

Last Name*
Tenth Child Date of Birth*
Tenth Child Signature*
Child Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver