A signed form for each camper must be returned before the participant may participate.

Parental Release Form

Application Number  
Camp Teen Extreme Youth Camp
Participant Name  
Address  
Phone Home:   Cell:  
School  
Church  

Emergency Parent Contact Information

Father’s Name  
Phone Work:   Cell:  
Mother’s Name  
Phone Work:   Cell:  

If a parent can’t be located, who should be contacted in case of an emergency?

Name  
Phone Home:   Cell:  
  • Does this camper have an emotional or behavioral problem?   Yes   No

    If yes, please explain on a separate sheet and also advise if he/she is under a doctor’s care for the problem.

  • Is this camper on any prescription medication?   Yes   No

    If yes, please list types and reasons for medication on a separate sheet.

Rock Climbing, FlowRider®, and Paintball Waiver and Release
(Must be completed by each participant, including sponsors, and sent with application)

I understand and agree that I am assuming for myself and the Participant named below all risk of injury from participating in rock climbing activities, surfing on the FlowRider® or paintball games. I understand that: (1) injuries while rock climbing may occur from rope entanglements, objects falling from or being dropped by other climbers, or from contact with anchor points, bolts, or equipment used in climbing; (2) injuries while using the FlowRider® may occur by falling or being thrown by the water pressure onto a fixed surface or padded retaining wall, or by contact with the body board; (3) the activities of paintball are physically and mentally intense, injuries while participating in paintball games may occur due to the activity and weaponry involved, and while particular protective equipment and personal discipline will minimize the risk, the risk of injury does exist and (4) other unforeseeable injuries may occur from these activities. I hereby waive, release, and agree not to sue Youth Outreach Ministry, Inc., Pensacola Christian College, Inc., its affiliates or subsidiaries, and any of their officers, directors, employees, agents, students, successors, or assigns for any damage, injury, cost, or cause of action arising from any participation in these activities.

I voluntarily sign this waiver, release and agreement not to sue with full knowledge of the nature and extent of the risks inherent in the use of the rock climbing wall, FlowRider®, and paintball. I further indemnify and save Youth Outreach Ministry, Inc., Pensacola Christian College and its affiliates, employees, and agents harmless from any liability or medical payments resulting from the participant's participation in this camp or other activities during his or her stay at summer camp. I further understand that Youth Outreach Ministry, Inc., does not provide medical insurance coverage for the participant and any medical expense incurred will be paid by me or my insurance. I hereby grant permission for the participant to attend the camp, participate in all the camp activities, and to be treated by a licensed medical professional in the event of any injury, accident or illness or other situation that may require medical attention. I give permission for the participant's picture to be used in future publications including publications from PCC and its affiliate web pages. I understand the enclosed registration fee is nonrefundable and nontransferable. Campers that use tobacco, alcohol or any form of illegal drugs will be dismissed. Any noncooperative or noncompliant campers will be subject to dismissal.

     
Parent/Legal Guardian’s Signature Relationship to Participant Date
   
Participant’s Signature Date

Medical Insurance This information prevents delay of treatment in case of emergency.

     
Insurance Company   Group ID
     
Insured’s name   Member ID

Send this signed form by mail to Youth Outreach Ministry, P.O. Box 18500, Pensacola, FL 32523 or by fax to 850-479-6576.