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Harvest Christian Fellowship Medical and Liability Release

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SCCC Inc. Adventure Activities: Release of Liability and Indemnity Agreement 

Harvest Christian Fellowship Medical and Liability Release

As a participant of 2019 Catalyst Summer Camp I agree to the following:

Medical Release: In the event of an emergency where medical treatment is required, I give permission to Harvest Christian Fellowship or Harvest Amarillo Church staff to obtain the services of a licensed physician. Please attempt to contact me immediately concerning any such emergency.

I Agree

Liability Release: In consideration of being permitted to participate in the Activity conducted by Harvest Christian Fellowship, Inc., Plainview, Texas, I, for myself and my legal representatives, heirs and assigns, hereby release, waive and discharge Harvest Christian Fellowship, Inc., Harvest Amarillo Church, and Sacramento Assembly (for housing and projects) its officers, elders, representatives, employees and members (collectively Harvest and Harvest Christian Fellowship), and each of them, from all liability to me for any and all loss or damage, and any claim or damages resulting there from, on account of injury to my person or property, whether caused by the negligence of Harvest Christian Fellowship, Harvest Amarillo.Church, Sacramento Assembly , or otherwise while I am involved in the Activity.

I hereby assume full responsibility for the risk of bodily injury, death, or property damage due to the negligence of Harvest Christian Fellowship, Harvest Amarillo Church, Sacramento Assembly , or otherwise while I am involved in the Activity.

I hereby expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Texas, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I Agree

Ministry Release: We are excited you chose to attend an event sponsored by Harvest Christian Fellowship where you can share and enjoy Christian fellowship. In many of our ministry events the Harvest Christian Fellowship and Harvest Amarillo Church ministry teams may pray and give Christian advice regarding a particular request by a participant. Our team is composed of lay volunteers and pastors who are not professionally trained or licensed in counseling. We are a church-based ministry providing guidance and spiritual counseling and deliverance ministries in individual and group settings. Our team is composed of lay volunteers and pastors who are not licensed counselors, as the state of Texas does not require such licensing. 

Spiritual Counseling Ministry Statement

What You Can Expect of Us: You can expect our ministry team to offer you acceptance, compassion and love as we provide Biblically based counseling that is within the scope of our ministry.

Biblical Basis: We believe that the Bible provides thorough guidance and instruction for faith and life. Therefore, our counseling is based on scriptural principles rather than theory of secular psychology or psychiatry. Neither the pastors not the lay volunteers of Harvest are trained or licensed as psychotherapists or mental health professionals, nor should they be expected to follow methods of such specialists.

Not Professional Advice: Some of our lay volunteers work in a professional function outside the church. When serving an event, volunteers within this ministry do not provide the same kind of professional advice and services they do in their professional capacities. Therefore, if you have significant legal, financial, medical or other technical questions, you should seek advice from an independent professional.

Qualification of Lay Event Leadership: Because of the Biblical and Spiritual nature of this ministry, we instruct our volunteers for a particular event. Lay volunteers do not possess professional licenses or certification for the practice of professional counseling, marriage, family therapy or social work specialties, nor do they necessarily possess the required education and expertise on training of such license.

Confidentiality: Under normal circumstances, everything you discuss with a pastor or a lay volunteer will be held in strict confidence. However, you should be aware there are some situations in which a pastor or lay volunteer may be required by law to report information to the proper authorities without your permission or knowledge. These situations include, but are not limited to: A persons indication of harm to self or others, involvement in a felony, suicidal intention and/or reasonable evidence of child or elder abuse or neglect. The pastor or lay volunteer may also disclose information in response to a subpoena issued by a court of law. Additionally, the pastor or lay volunteer may also disclose information in the event he/she deems it relevant.

Having clarified the principles and policy for Harvest Event Ministry, We Welcome the opportunity to minister to you in the Name of Christ and to be used by Him as He helps you to grow in spiritual maturity and usefulness in His Body. If these guidelines are acceptable to you, please agree to our waiver of liability below.

I Agree


Date: June 24, 2019

SCCC Inc. Adventure Activities: Release of Liability and Indemnity Agreement 

All PARTICIPANTS/PARENT/GUARDIAN, BY SIGNING HIS/HER NAME AT THE BOTTOM OF THIS RELEASE, AGREES THAT FOR AND IN CONSIDERATION OF THE OPPORTUNITY TO BE AROUND AND/OR PARTICIPATE IN “ADVENTURE PROGRAMMING”, PROVIDED BY SACRAMENTO CAMP AND CONFERENCE CENTER, INC. (HEREINAFTER CALLED “RELEASED PARTY”) HEREBY AGREES TO PAY FOR SUCH PARTICIPATION (IF REQUIRED), AND FURTHER AGREES AS FOLLOWS:

(1)  THAT RELEASED PARTY, ITS AGENTS, SERVANTS, OR EMPLOYEES, HAVE EXPLAINED TO ME THAT THE RELEASED PARTY’S DUTY TO THE PUBLIC REQUIRES THEM TO DESCRIBE THE NATURE OF THIS SERVICE PERFORMED HERE IN PROVIDING ADVENTURE RELATED ACTIVITIES FOR MY USE, THAT I CLEARLY UNDERSTAND THE FAIRNESS AND MEANING OF THIS RELEASE AGREEMENT, & I ACKNOWLEDGE THAT I HAVE BEEN GIVEN AN OPPORTUNITY TO ASK ANY QUESTIONS CONCERNING THIS MATTER;

(2)  THAT I KNOW & UNDERSTAND THAT THESE ADVENTURE ACTIVITIES, INVOLVES SPECIFIC RISKS OF PROPERTY DAMAGE OR PERSONAL INJURY TO ME OR TO MY MINOR CHILDREN ARISING FROM ACTIVITIES RELATED TO PARTICIPATING IN THESE ADVENTURE PROGRAMS. THIS ALSO INCLUDES THE RISK THAT THE RELEASED PARTY OR ITS SERVANTS, AGENTS OR EMPLOYEES MAY ACT NEGLIGENTLY IN SELECTING, PREPARING OR MAINTAINING THE EQUIPMENT OR PREMISES, IN ASSISTING ME OR MY MINOR CHILDREN TO PARTICIPATE IN, MOUNT, DISMOUNT, LOAD, CLIMB, ETC FROM THE EQUIPMENT, APPARATUS, HORSE OR HORSE-DRAWN VEHICLE, OR IN OTHERWISE SUPERVISING THE ACTIVITIES: BUT THAT I NEVERTHELESS INTENTIONALLY AGREE TO ASSUME THESE RISKS;

(3)  I, FOR MYSELF AND/OR ON BEHALF OF MY CHILD OR LEGAL WARD, HAVE BEEN FULLY WARNED AND ADVISED BY RELEASED PARTY. THAT WHEN REQUIRED, WE WILL WEAR PROPERLY FITTED SAFETY EQUIPMENT OR CLOTHING SUCH AS CLOSED TOED SHOES, GLOVES, GOGGLE, ETC. OR HELMET IN ORDER TO REDUCE SOME OR ALL OF POTENTIAL INJURIES AS THE RESULT OF A FALL OR ANY OTHER OCCURRENCE ASSOCIATED WITH THIS HAZARDOUS ACTIVITY. WE REALIZE THAT WE ARE SUBJECTTO INJURY FROM THESE ACTIVITIES TO WHICH WE ARE EXPOSING OURSELVES PURELY VOLUNTARILY.

(4)  I HEREBY DECLARE THAT I OR MY CHILD IS PHYSICALLY FIT. I OR MY CHILD DO NOT, AND HAVE NOT, SUFFERED FROM ANY OF THE FOLLOWING CONDITIONS, WHICH I UNDERSTAND MAY LEAD TO A DANGEROUS SITUATION WITH REGARD TO OTHER PERSONS OR MYSELF DURING ADVENTURE ACTIVITIES: PREGNANCY, EPILEPSY, SEIZURES,

(5)  SEVERE HEAD INJURY, RECURRENT BLACKOUTS OR GIDDINESS, DISEASE OF THE BRAIN OR NERVOUS SYSTEM, HIGH BLOOD PRESSURE, LUNG OR HEART DISEASE, RECURRENT WEAKNESS OR DISLOCATION OF ANY LIMB, DIABETES, MENTAL ILLNESS, DRUG OR ALCOHOL ADDICTION, RECENT BACK INJURY, ARTHRITIS AND SEVERE JOINT SPRAINS, CHRONIC BRONCHITIS, ASTHMA, RHEUMATIC FEVER, THYROID, ADRENAL OR OTHER GLANDULAR DISORDER, RECENT BLOOD DONATION OR ANY OTHER CONDITION THAT REQUIRES THE REGULAR USE OF DRUGS, I HEREBY DECLARE THAT I HAVE NO PHYSICAL OR MENTAL CONDITION THAT SHOULD PRECLUDE ME FROM PARTICIPATING IN MY CHOSEN ACTIVITY, THAT I AM NOT PARTICIPATING AGAINST MEDICAL ADVICE OR TREATMENT AND THAT I HAVE NOT BEEN DIAGNOSED BY A REGISTERED DOCTOR AS HAVING A TERMINAL ILLNESS. I FURTHER DECLARE THAT IN THE EVENT THAT I FEEL ILL OR UNWELL, HAVE ANY PHYSICAL COMPLAINTS WHATSOEVER OR IF AN INJURY IS SUSTAINED OF ANY KIND DURING THE COURSE OF ADVENTURE ACTIVITIES, I WILL NOTIFY THE FACILITATOR/EMPLOYEE OF THE INSURED IMMEDIATELY AND BEFORE MOVING AWAY FROM THE IMMEDIATE VICINITY.

(6)  THAT I HEREBY RELEASE AND FOREVER DISCHARGE RELEASED PARTY, ITS AGENTS, SERVANTS OR EMPLOYEES FROM ALL PRESENT AND FUTURE CLAIMS ARISING FROM PERSONAL INJURY OR PROPERTY DAMAGE SUSTAINED BY ME OR BY MY MINOR CHILDREN DURING THE USE OF THE PROPERTY, EQUIPMENT, ATV, HORSE OR HORSE-DRAWN VEHICLE, AND ALL OTHER RELATED EQUIPMENT OF RELEASED PARTY, WHETHER OR NOT LOSS, DAMAGE OR INJURY RESULTED FROM THE NEGLIGENCE OF RELEASED PARTY OR ITS AGENTS, SERVANT OR EMPLOYEES AND RELEASED PARTY’S FAILURE TO USE DUE CARE, EITHER IN ITS TRAINING METHODS OR IN ITS FURNISHING SAFE EQUIPMENT, AND I SHALL ASSUME ALL RISKS RELATED TO BEING AROUND OR OBSERVING ACTIVITY PROGRAMMING, SHOOTING SPORTS, ATVS, HORSES, HORSEBACK RIDING OR RIDING HORSE-DRAWN VEHICLES, ETC. 

(7)  THAT I WAIVE MY RIGHT TO FILE AND PROMISE NOT TO FILE ANY LEGAL PROCEEDINGS AGAINST RELEASED PARTY, ITS AGENTS, SERVANTS OR EMPLOYEES, FOR ANY PERSONAL INJURY OR PROPERTY DAMAGE SUSTAINED BY ME OR BY MY MINOR CHILDREN DURING

THESE OR ANY ACTIVITY, INCLUDING DAMAGE ARISING OUT OF NEGLIGENCE BY RELEASED PARTY, ITS AGENTS, SERVANTS OR EMPLOYEES; AND I SHALL PAY ALL COSTS AND ATTORNEYS’ FEES FROM ANY LEGAL PROCEEDINGS WHICH I MAY BRING CONTRARY TO THIS AGREEMENT AND WHICH IS RESOLVED IN FAVOR OF RELEASED PARTY, ITS AGENTS, SERVANTS OR EMPLOYEES;

(8)  WHERE APPLICABLE I WILL READ ALL RULES AND REGULATIONS POSTED, HANDED OUT, OR VERBALLY EXPLAINED TO ME OR MY CHILD AND ABIDE BY THOSE RULES AND REGULATIONS

(9)  IF PARTICIPATION IN EQUESTRIAN ACTIVITY: THAT I SIGN THIS RELEASE AGREEMENT FOR AND IN CONSIDERATION OF THE AGREED PRICE, AND I HEREBY REQUEST RELEASED PARTY, ITS AGENTS, SERVANTS OR EMPLOYEES, TO CHOOSE FOR ME OR FOR MY MINOR CHILDREN A HORSE OR HORSE-DRAWN VEHICLE, FOR THE PURPOSE OF BEING AROUND HORSES OR RIDING SAME, KNOWING THAT RELEASED PARTY, ITS AGENTS, SERVANTS, OR EMPLOYEES ARE RELYING UPON THIS RELEASED AGREEMENT AND THE INFORMATION THAT I HAVE GIVEN TO THEM CONCERNING MY EXPERIENCE AND THAT OF MY MINOR CHILDREN WITH HORSES AND HORSE-DRAWN VEHICLES, INCLUDING THE POTENTIAL HAZARDS INVOLVED;

WARNING

UNDER NEW MEXICO LAW, AN EQUINE ACTIVITY SPONSOR OR AN EQUINE PROFESSIONAL IS NOT LIABLE FOR AN INJURY TO OR THE DEATH OF A PARTICIPANT IN EQUINE ACTIVITIES RESULTING FROM THE INHERENT RISKS OF EQUINE ACTIVITIES, PURSUANT TO NEW MEXICO STATUTES 42-13

(10)  THAT I HAVE READ THE FOREGOING RELEASE, AND BEING OF SOUND MIND AND AN ADULT, SIGN IT FREELY WITH FULL KNOWLEDGE OF ITS MEANING AND CONTENT.

(11)  THIS RELEASE FORM COVERS THE FOLLOWING ACTIVITIES ALL ACTIVITIES INCLUDE BUT MAY NOT BE LIMITED TO: ARCHERY, ARCHERY TAG, SLIP N SLIDE, SHOOTING SPORTS (.22 RIFLE, TRAP, SKEET, FIREARM SAFETY, HANDGUN INSTRUCTION, OPEN RANGE, BB GUNS,) KNIFE THROWING, CHALLENGE COURSE (INDOOR/OUTDOOR, ZIP LINE, GIANT SWING, ETC.), PAINTBALL, POCKET SHOT PAINTBALL, LASER TAG, RC CARS/BOATS, FLING THING, ATV RIDING, MOUNTAIN SCOOTERS, PEDAL CARTS, PADDLE BOATS, ROLLER/ICE SKATING, SNOW SLEDDING,(AND OTHER WINTER SPORTS), FISHING, HIKING, SEMINARS, GYM/SPORTS FIELD ACTIVITIES, CAMP OUTS, CAMPFIRES, AND ALL HORSE ACTIVITIES (RIDING/WAGON RIDES/EQUINE THERAPY/ROUND PEN DEMOS)

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
Participant's 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*
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact 1

Name: *

Phone Number: *

Relationship to Participant: *
Emergency Contact 2

Name: *

Phone Number: *

Relationship to Participant: *
Insurance Information

Insurance Company: *

Policy Number: *

Policy Holder Name: *

Participants covered by this policy: *

If secondary (or different) insurance for any participant please list company:

Policy Number:

Policy Holder:

Participants Covered:
Activity Exclusions
Are there any activities participant should be excluded from?*
No
Yes

If so please list:
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 Information
Will you be bringing medication to camp?*
No
Yes

If bringing medication please list:

Medication Instructions:
Does participant have any allergies?*
No
Yes

If allergies please list:

Notes:
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.


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