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Participant Waiver Form
Massanetta Springs Camp and Conference Center

Covenant of Christian Behavior for All Mission at Massanetta Participants (Youth and Adults)

A covenant is an agreement by which we strive to abide as we live together in Christian community.  It provides guidelines for relating with each other within the family of God and enables everyone to feel safe and cared for.  Following these guidelines enables us to provide a positive Christian witness to others, especially those we are serving.

As a member of this intentional Christian community, I covenant to:

  • Participate fully in the program of Mission at Massanetta
  • Act with respect for myself and others; follow the golden rule
  • Demonstrate respect for adult leadership, abiding by all reasonable direction
  • Treat the property and grounds of Massanetta Springs and all work sites with respect
  • Refrain from alcohol and drug use, sexual activity, profanity  and all forms of bullying
  • Abide by the tobacco policies of all sites visited
  • Wear clothing which is sufficiently modest for this context and that is free from controversial language and images
  • Be responsible for my own belongings and respect the property of others
  • Notify an adult immediately if any participant is engaging in dangerous behavior
  • Notify an adult immediately if any participant expresses the intent to harm him or herself or another person

I voluntarily join this covenant community, and I agree to abide by this covenant while I am part of it.  I understand that breaking this covenant may result in my being sent home at my / my parent’s expense.

Massanetta Conference Participant Covenant 

As a participant, I agree to the following covenant: I have willingly chosen to participate in the Massanetta Springs Middle School Conference. As a participant, I will work towards the goals of this event and the building of our group into a Christian community by:

 participating wholeheartedly and enthusiastically in all activities planned for my group

 speaking up when I have a problem or need

 listening and responding to the needs of others

 following the guidance of all adult leadership

 respecting the rights and property of others, and abiding by the rules of the Conference Center

 not using or promoting the use of controlled substances (alcohol, drugs, tobacco, flammables)

 not leaving the event grounds without my adult leader present

 encouraging others to understand and abide by this covenant, and striving to live as a supportive member of the group, and as a good example to those with whom we are in contact.

 if I am an adult, I will also abide by the convenant guidelines as stated at the bottom of this page I understand that abiding in this covenant will result in a positive group experience. I understand that failure to abide by these guidelines may result in being sent home at my parent’s/ guardian’s expense.

Participant Signature:


Date: March 29, 2020

As the parent of the Participant named above, I have reviewed this covenant with my son or daughter; I understand that if it is necessary for him or her to return home, it will be my responsibility to provide transportation and cover costs.

As the parent/guardian of this participant, in signing this Registration Form, I agree to the following:

 I give permission for my son/daughter to participate in the Middle School Conference.

 I am aware of and approve of the planned costs, dates, places, and activities of this event.

 I understand the degree of risk (if any) involved in this event and because I trust the adult leadership and my child, I hereby release Massanetta Springs Conference Center, and any of the adult leadership at the Middle School Conference, from any liability for any injury or problem occurring during participation in this event.

 I have completed all the Registration Form and it is correct to the best of my knowledge. I understand that all reasonable attempts will be made to contact me in the case of an accident involving my son or daughter. In the event that I cannot be reached, I hereby give permission to the physician selected by my youth’s adult advisor, or the Conference leadership, to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my son or daughter.

Parent/ Guardian or Adult Chaperone Signature:


Date: March 29, 2020

Consent Form:

I/We do hereby give permission for my/our child to attend and participate in the 2020 Mission@Massanetta & Massanetta Springs Middle School Conference summer trip to Harrisonburg, VA, from July 12-17, 2020.

In the event of an emergency, I/we do also hereby give permission to the adult leaders as representatives of Broad Street Presbyterian Church to act in my/our behalf to consent to any medical treatment or hospitalization deemed necessary by the leaders and a licensed physician or emergency team.  I/We agree to be liable to any and all costs involved in such emergency treatment.  I/We release and discharge Broad Street Presbyterian Church and/or representatives involved in this activity from any liability in exercising this permission.  The health information on this form is true to the best of my/our knowledge and I/we give permission to the leaders to dispense medications as directed and indicated on this form to my child.

I/we waive any claim against Massanetta Springs or its agents, as well as the work sites and their agents. These may include, but are not limited to: Massanetta Springs Camp and Conference Center; The Arc; Boys & Girls Club; Elkton Area United Services; Equipping the Saints; Generations Crossing; Harrisonburg Redevelopment Authority; Mercy House Thrift Shop; Rebuilding Together of Harrisonburg; Renewing Homes of Greater Augusta; Roberta Webb Child Care Center; SPCA of Rockingham / Harrisonburg.

In the event of an emergency, I/we understand that every attempt will be made to contact the parent/guardian.  In the event that the parent/guardian cannot be reached, I/we give permission to Massanetta Springs to secure medical treatment, and that the responsibility for medical expenses rests with me/us.

I give permission for my/our photograph to be taken and used in any publication of Massanetta Springs or any of the work sites.  (Strike through this item if you do not wish to be photographed.)

Parent/ Guardian or Adult Chaperone Signature:


Date: March 29, 2020
 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

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

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
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*

Confirm Email*
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

All Current Medications:

List Allergies (and proper medical response if exposed):

Medical conditions, behavioral health, or physical limitations of the participant:

Gender:
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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