Fall Youth Retreat 2018

Student's Name

Date of Birth

Student's Email

Student's Cell Phone number

Grade

Gender

Male Female

Coming with a friend? List friend's name here.

Medical Information

Medical Insurance provider

Policy/Group #

If you check any of the above, please list approximate dates.

Allergies Bee Stings Penicillin Other (list below)

If you listed "Other", please list allergies here.

Dietary Restrictions?

Surgeries within past two years?

Other Pertinent information

Over-the-counter medications the participant is NOT to have

Parent's Information

Parent's Name

Parent's Email

This address will receive a confirmation email

Parent's Cell Phone Number

Day Phone Number

Evening Phone Number

Emergency Name and Phone number in case parent cannot be reached

Address

Content and Releases

Parents/Guardians - Please read the Retreat Releases and permission forms carefully below and "sign" by typing your name in the spaces provided. Thank you.

Parental Consent (must be complete for all those age 18 and under.) In case of emergency, I understand that every effort will be made to contact me. I hereby give my permission to the physician chosen by Three Springs Ministries’ staff and/or the sponsoring group’s staff to hospitalize and/or secure proper treatment for, and order injections, or anesthesia, or surgery for my child as named on this form. Also, for promotional purposes only, the camp has my permission to use pictures or videos that should happen to include my child.

Parental Consent: If participant is under eighteen (18) years of age, the undersigned parent/guardian, hereby authorizes his/her son or daughter to attend the 2018 Fall Retreat at Three Springs Ministries on November 9-11. In the event of an emergency, said parent or guardian understands that all will be done to contact him/her. However, if the parent/guardian cannot be reached, permission is granted to the physician selected by the youth leader to hospitalize and/or secure proper treatment for, and to order such injections, anesthesia, or surgery as may be deemed necessary for the child’s welfare and protection. The undersigned parent/guardian further acknowledges that his/her son or daughter may be photographed or captured on video as a participant on the 2018 Fall Retreat, and grant full permission to Westminster Presbyterian Church to use photographs or videos in print, electronic, or public form.

Parent Release: The undersigned participant, and participant’s guardian if participant is under eighteen (18) years of age on the date hereinafter indicated, does hereby release and discharge Westminster Presbyterian Church, its agents, youth leaders, employees, volunteers, and representatives, from any and all liability in connection with any activities carried on during its 2018 Fall Retreat, November 9-11, including but not limited to claims of negligence, recklessness and any and all other claims alleging a failure to use reasonable care, including but not limited to claims made in connection with the use of transportation vehicles, facilities, buildings, land, fixtures, rock climbing, basketball, challenge course elements, ice and snow sports, airsoft, work activities, and various field games and any other activities of any nature whatsoever conducted during its 2017 Fall Retreat. The undersigned hereby acknowledge that they have assumed all risk, known or unknown, in connection with transportation to and from and participation in the 2018 Fall Retreat.

Sudent's Signature

Participant's Release (Three Springs): The undersigned participant, and guardian if under eighteen (18), on the date hereinafter indicated, does hereby release and discharge THREE SPRINGS MINISTRTIES, INC., its agents, servants, employees, workmen, directors, trustees, and representatives, from any and all liability in connection with any activities carried on at THREEE SPRINGS MINISTRIES, INC., or any other location used by or involving THREE SPRINGS MINISTIRES, INC., including but not limited to claims of negligence, recklessness and any and all other claims alleging a failure to use reasonable care, including but not limited to claims made in connection with the use of the facilities, buildings, land, fixtures, horses, saddled animals, rock climbing, basketball, mountain biking, canoeing, challenge course elements, backpacking, ice and snow sports, paintball, swimming, work activities, and various field games and any other activities of any nature whatsoever. The undersigned hereby acknowledge that they have assumed all risk, known or unknown, in connection with the use of the facilities, including but no limited to all buildings, land, facilities, horses, saddled animals, rock climbing wall and apparatus, ice and snow sports, sports equipment, camping equipment, and any other buildings, land, fixtures and equipment at the said THREE SPRINGS MINISTRIES, INC., or any other location used by or involving THREE SPRINGS MINISTRIES, INC. The risks assumed include, but are not limited to risks associated with the use of buildings, land, facilities, equipment, fixtures, all risk associated with all activities, animals, terrain, and danger of injury. The undersigned hereby releases THREE SPRINGS MINISTRIES,INC., its agents, servants, employees, workmen, representatives, directors and trustees from any and all claims, damages, reckonings for personal injury, property damage, medical expenses, wage loss, pain and suffering, including but not limited to claims of negligence, recklessness, failure to use reasonable care in any way, failure to supervise or instruct or any other act or omission of negligence or recklessness, wrongful death claims or other types of claims and damages on account of injury, accident or disease, which the undersigned may receive on account of the use of the facilities including but not limited to use of any of the buildings, any portion of the land, horses, saddled animals, rock climbing, mountain biking, canoeing, challenge course elements, backpacking, ice and snow sports, paintball, swimming, mountain biking, basketball, work activities, and various field games and any other activities of any nature whatsoever. This release encompasses both onsite and off site activities. This release encompasses, but is not limited to, all claims of premises liability of any nature whatsoever. Also, the undersigned agrees to indemnify, defend and hold harmless THREE SPRINGS MINISTRIES, INC., its employees, agents, servants, workmen, directors, trustees and representatives, from any and all claims arising from the use of the land, buildings, any saddled animals or other animals, rock climbing, mountain biking, canoeing, challenge course elements, backpacking, ice and snow sports, paintball, swimming, basketball, work activities, and various field games and any other activities of any nature whatsoever, and agrees to defend THREE SPRINGS MINISTRIES and pay THREE SPRINGS MINISTRIES’ attorneys fees in connection with any suit filed by the undersigned on account of such claims for damages or injuries sustained at THREE SPRINGS MINISTRIES or any other locations operated or used by THREE SPRINGS MINISTRIES, INC. The consideration for this release is the privilege of being involved in the ministry as a participant and user of facilities. This release may not be changed orally.

Let us know if you will be doing one of the following (select one and pay on the trip): Horseback riding Rock Wall Climbing

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Fall Youth Retreat 2018

Description

Please Fix the Following