Empty Youth Camp Online Registration Form
 
Sponsoring Church:  Green Valley Baptist Church
Camp Location:  Green Valley Baptist Church, 3110 Cook Rd., St. Joseph, MO 64506
Total Cost:  $100/per student (Deadline: June 28, 2017)
 
 
Medical Release: Waiver & Release – Green Valley Baptist Church – Illuminate Student Ministries
Consideration:  I acknowledge the personal benefits accruing to me (and my child/student, as applicable) by reason of participation in the above described event and am aware of the activities in which I, or my child/student, will be involved through said participation.
 
Release/Indemnification:  I hereby, in consideration of such benefits received, consent to the above listed participation and release absolutely, forever discharge, hold harmless and covenant not to sue Green Valley Baptist Church, its host location property holder(s), its employees and volunteers from any and all present or future liability, claims, demands, actions or rights of action, whether asserted by me or a third-party arising out of my or my child/student’s participation in event activities.  I agree to indemnify and hold harmless Green Valley Baptist Church, it’s leaders and volunteers and the host location property holder(s) where the above stated event shall take place for any such claims brought by me or a third party from any costs associated with defending or litigating such claims, including but not limited to attorney fees, costs and legal expenses.
 
Assumption of Risk:  I am aware of the risks associated with participation in the above event and do hereby voluntarily assume full responsibility for any risk of loss, property damage or personal injury, including death, that may result from participation in event activities.
 
Medical Emergency:  In the event of injury or a medical emergency, (1) I give permission for Green Valley Baptist Church’s adult leaders to pursue immediate medical treatment, (2) I release Green Valley Baptist Church, it’s adult leaders (both employees and volunteers) and the property owners of the location above stated event from any and all liability related to medical treatment.  In addition, (3) I assume the risk and financial responsibility for any injury resulting from the attendee’s participation in all activities related to the above stated event.
 
Authorization Addendum:  I acknowledge that during my or my child’s/student’s participation in the above stated event that certain risks do exist.  These include, but are not limited to, the hazards of travel by automobile, the risks involved in recreational games, those risks existing at locations such as beach, lake or other waterway, and other hazards that could result in illness or the loss of life or property.  In consideration of this acknowledgement, I voluntarily have and do hereby, assume all risks associated with my or my child’s/student’s participation in the above stated event.
 
Understanding:  I represent and acknowledge that I have completely read and understand this document and all its terms and all matters referred to herein, and I signed/initialed voluntarily as my free act and deed, that I have had an ample opportunity to obtain the advice of counsel and that, by signing this document, I understand that I am relinquishing legal rights and remedies that may have otherwise been available to me.  I understand that this Waiver and Release shall be construed as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document is held invalid, the remaining shall continue in full force and effect.  To the extent that the restriction on filing lawsuits is deemed unlawful, I agree to submit any claims to a Christian conciliation/mediation organization for binding resolution.
 
CAUTION:  READ THIS ENTIRE DOCUMENT BEFORE INITIALING BELOW. 
THIS IS A GENERAL RELEASE AND INDEMNIFICATION OF CLAIMS.
 
PLEASE FILL OUT ALL FIELDS BELOW

    Your Name (required)

    Your Age (required)

    Your Grade in School Fall 2017 (required)

    Name of Your School (required)

    Your Street Address (required)

    Your City (required)

    Your State (required)

    Your Zip (required)

    Home Phone (required)

    Parent/Guardian (required)

    Parent/Guardian Cell Phone #1 (required)

    Parent/Guardian Cell Phone #2 (required)

    Student Cell Phone (required)

    Parent's Email (required)

    Student's Email (required)

    Emergency Contact (required)

    Emergency Contact - Relationship (required)

    Emergency Contact - Phone # (required)

    Insurance Company Name (required)

    Insurance Policy # (required)

    Insurance Group # (required)

    Special Considerations - Please list ANY allergies, food allergies or special conditions we should know about: (required)

    Medication to be administered at camp: (required)

    I've read and understand the Medical Release (required)

    YesNo

    Student Initials (required)

    Parent Initials (required)