This is it! You found it! Hopefully all the forms you will need can be found right here! If you have any questions, please contact us at:
Raylene Burns 316-519-1480 / Abbey Zimmerman 316-990-8892 / [email protected]
Raylene Burns 316-519-1480 / Abbey Zimmerman 316-990-8892 / [email protected]
CHRISTIAN HILLS CAMP WAIVER FOR CAMPERS
CAMPER CANNOT BE ADMITTED WITHOUT THIS FORM
CAMPER NAME:_______________________________ CAMP DATES:__________________
Sex (circle): F M Birthday:____/____/______ Age:_________ Weight:________ Height:______
Address:________________________ City:_______________State:_______ Zip:___________
Home Phone (____)____________Work Phone (____)___________ Cell Phone (____)_____________
Emergency contact: ______________________________Phone Number (____)___________
HEALTH AND GENERAL MEDICAL HISTORY
If the camper should be restricted on any activities please note: _________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If the camper is TAKING ANY KIND OF MEDICATION during camp please note the drug and the dosage:
___________________________________________________________________________
Please note any medical condition or medical history that would require special attention:
____________________________________________________________________________
____________________________________________________________________________
I hereby certify that the named camper is in good health and fully able to participate in all activities at Christian Hills Camp. My camper has no known restrictions, or any other facts, that may limit her/him from participation.
Signed:__________________________________________________Date:_______________
Please circle those illnesses or conditions that the camper has had:
German Measles Measles Mumps Asthma Chicken Pox Pneumonia Diabetes
High Blood Pressure Other_________________________________________________
IMMUNIZATIONS (dates): ALLERGIES: _________________ DRUG REACTIONS:________________
Tetanus Toxoid:______________________________________________________________________
Tuberculin Test:______________________________________________________________________
Measles:____________________________________________________________________________
Rubella:_____________________________________________________________________________
Mumps:_____________________________________________________________________________
I HAVE READ THE REGISTRATION PACKET AND FULLY UNDERSTAND OUR OBLIGATIONS STATED
THEREIN AND ALSO THE RIGHTS OF HIGH POTENTIAL ACTIVITES, AND HERBY AGREE IN ACCORDANCE. I further understand that Christian Hills Camp retains the right to use photographs of campers taken at camp.
Signed ___________________________________________ Date:_________________
WAIVER & RELEASE
In consideration of participating in any campground activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising for negligence
Christian Hills Camp and it’s owners, directors, officers, employees, agents, volunteers, participants, and all other persons or entities acting for them (hereafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate and also agree as follows:
1. I acknowledge that participating in camp activities involves known and unanticipated risks
which could result in physical or emotional injury, paralysis or permanent disability, death,
and property damage. Risks include, but are not limited to, broken bones, torn ligaments or
other injuries as a result of falls or contact with other participants,; death as a result of
drowning or brain damage caused by near drowning in polls or other bodies of water;
medical conditions resulting from physical activity; and damaged clothing or other property.
I understand such risks simply cannot be eliminated, despite the use of safety equipment,
without jeopardizing the essential qualities of the activity.
2. I expressly accept and assume all of the risks inherent in this activity that might have been
caused by the negligence of the Releasees. My participation in this activity is purely
voluntary and I elect to participate despite the risks. In addition, if at any time I believe that
event conditions are unsafe or that I am unable to participate due to physical or medical
conditions, then I will immediately discontinue participation.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless
Releasees from any and all claims, demands, or causes of action, which are in any way
connected with my participation in this activity, or my use of their equipment or facilities,
arising from negligence. This release does not apply to claims arising from intentional
conduct. Should Releasees or anyone acting on their behalf be required to incur attorney
fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for
all such fees and costs.
4. I represent that I have adequate insurance to cover and injury or damage I may suffer or
cause while participating in this activity, or else I agree to bear the costs of such injury or
damage myself. I further represent that I have no medical or physical condition which could
interfere with my safety in this activity, or else I am willing to assume-and bear the costs of-
all risks that may be created, directly or indirectly, by any such condition.
5. In the event that I file a lawsuit, I agree to do so solely in the state where Releasees’ facility
is located, and I further agree that the substantive law of that state shall apply.
6. I agree that if any portion of this agreement is found to be void or unenforceable, the
remaining portions shall remain in full force and effect.
(continued)
By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.
I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not me made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain.
I have read and understood this document and I agree to be bound by its terms.
Signature_____________________________ Print Name ____________________________
Representing (Event) __________________________________________________________
Address______________________ City__________________ State_______Zip__________
Phone (_____)__________________________ Date_________________________
PARENT OR GUARDIAN ADDITIONAL AGREEMENT
In consideration of ____________________________(print minor’s name) being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.
Parent/Guardian ______________________Print Name_____________________Date________
(If notarization is necessary, please sign & stamp this side of form)
HEALTH INSURANCE INFORMATION
Health Insurance Company: ___________________________________________________________________
Policy/ID Number: ___________________________________________________________________
Policy Holder Name: ___________________________________________________________________
Policy Holder Date of Birth:________/_________/_______________
CAMPER CANNOT BE ADMITTED WITHOUT THIS FORM
CAMPER NAME:_______________________________ CAMP DATES:__________________
Sex (circle): F M Birthday:____/____/______ Age:_________ Weight:________ Height:______
Address:________________________ City:_______________State:_______ Zip:___________
Home Phone (____)____________Work Phone (____)___________ Cell Phone (____)_____________
Emergency contact: ______________________________Phone Number (____)___________
HEALTH AND GENERAL MEDICAL HISTORY
If the camper should be restricted on any activities please note: _________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If the camper is TAKING ANY KIND OF MEDICATION during camp please note the drug and the dosage:
___________________________________________________________________________
Please note any medical condition or medical history that would require special attention:
____________________________________________________________________________
____________________________________________________________________________
I hereby certify that the named camper is in good health and fully able to participate in all activities at Christian Hills Camp. My camper has no known restrictions, or any other facts, that may limit her/him from participation.
Signed:__________________________________________________Date:_______________
Please circle those illnesses or conditions that the camper has had:
German Measles Measles Mumps Asthma Chicken Pox Pneumonia Diabetes
High Blood Pressure Other_________________________________________________
IMMUNIZATIONS (dates): ALLERGIES: _________________ DRUG REACTIONS:________________
Tetanus Toxoid:______________________________________________________________________
Tuberculin Test:______________________________________________________________________
Measles:____________________________________________________________________________
Rubella:_____________________________________________________________________________
Mumps:_____________________________________________________________________________
I HAVE READ THE REGISTRATION PACKET AND FULLY UNDERSTAND OUR OBLIGATIONS STATED
THEREIN AND ALSO THE RIGHTS OF HIGH POTENTIAL ACTIVITES, AND HERBY AGREE IN ACCORDANCE. I further understand that Christian Hills Camp retains the right to use photographs of campers taken at camp.
Signed ___________________________________________ Date:_________________
WAIVER & RELEASE
In consideration of participating in any campground activities, and for other good and valuable consideration, I hereby agree to release and discharge from liability arising for negligence
Christian Hills Camp and it’s owners, directors, officers, employees, agents, volunteers, participants, and all other persons or entities acting for them (hereafter collectively referred to as “Releasees”), on behalf of myself and my children, parents, heirs, assigns, personal representative and estate and also agree as follows:
1. I acknowledge that participating in camp activities involves known and unanticipated risks
which could result in physical or emotional injury, paralysis or permanent disability, death,
and property damage. Risks include, but are not limited to, broken bones, torn ligaments or
other injuries as a result of falls or contact with other participants,; death as a result of
drowning or brain damage caused by near drowning in polls or other bodies of water;
medical conditions resulting from physical activity; and damaged clothing or other property.
I understand such risks simply cannot be eliminated, despite the use of safety equipment,
without jeopardizing the essential qualities of the activity.
2. I expressly accept and assume all of the risks inherent in this activity that might have been
caused by the negligence of the Releasees. My participation in this activity is purely
voluntary and I elect to participate despite the risks. In addition, if at any time I believe that
event conditions are unsafe or that I am unable to participate due to physical or medical
conditions, then I will immediately discontinue participation.
3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless
Releasees from any and all claims, demands, or causes of action, which are in any way
connected with my participation in this activity, or my use of their equipment or facilities,
arising from negligence. This release does not apply to claims arising from intentional
conduct. Should Releasees or anyone acting on their behalf be required to incur attorney
fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for
all such fees and costs.
4. I represent that I have adequate insurance to cover and injury or damage I may suffer or
cause while participating in this activity, or else I agree to bear the costs of such injury or
damage myself. I further represent that I have no medical or physical condition which could
interfere with my safety in this activity, or else I am willing to assume-and bear the costs of-
all risks that may be created, directly or indirectly, by any such condition.
5. In the event that I file a lawsuit, I agree to do so solely in the state where Releasees’ facility
is located, and I further agree that the substantive law of that state shall apply.
6. I agree that if any portion of this agreement is found to be void or unenforceable, the
remaining portions shall remain in full force and effect.
(continued)
By signing this document, I agree that if I am hurt or my property is damaged during my participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence.
I have had sufficient time to read this entire document and, should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not me made available to me or that the cost to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain.
I have read and understood this document and I agree to be bound by its terms.
Signature_____________________________ Print Name ____________________________
Representing (Event) __________________________________________________________
Address______________________ City__________________ State_______Zip__________
Phone (_____)__________________________ Date_________________________
PARENT OR GUARDIAN ADDITIONAL AGREEMENT
In consideration of ____________________________(print minor’s name) being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.
Parent/Guardian ______________________Print Name_____________________Date________
(If notarization is necessary, please sign & stamp this side of form)
HEALTH INSURANCE INFORMATION
Health Insurance Company: ___________________________________________________________________
Policy/ID Number: ___________________________________________________________________
Policy Holder Name: ___________________________________________________________________
Policy Holder Date of Birth:________/_________/_______________