Teen Extreme Youth Camp

Parental Release Form

(This is for those who have already applied for camp.)

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

Emergency Information

   
Parent’s Name: Parent’s Work Phone:
   
Parent’s Home Phone: Parent’s Cell Phone:
If a parent can’t be located, who should be contacted in case of an emergency?

If you have medical insurance, attach a copy of the insurance card (front and back) and prescription card for hospital use. This prevents any delay of treatment in case of emergency.

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.


Does this camper have a history of violent behavior toward any other children? ___ Yes ___ No

Is this camper on any prescription medication? ___ Yes ___ No
If yes, please list types and reasons for medication on a separate sheet.

A signed form for each camper must be received by Youth Outreach Ministry before camper may participate.

I understand and agree that I am assuming for myself and the Participant named above 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 voluntarily sign this waiver and 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 with full knowledge of the nature and extent of the risks inherent in the use of the rock climbing wall, FlowRider®, and paintball.

I indemnify and hold Youth Outreach Ministry, Inc., Pensacola Christian College, Inc.; and its affiliates, employees, volunteers, and agents harmless from any and all claims or liability or medical payments resulting from my child’s participating in this camp or other activities during his/her stay at summer camp. I further understand that Youth Outreach Ministry does not provide medical insurance coverage for my child and that any medical expenses incurred will be paid by either my own medical insurance or me. I hereby grant permission for my child to attend the camp, to participate in all the camp activities, and to be treated by a licensed medical professional in the event of any injury, accident, illness, or other situation that may require medical attention, including hospitalization, anesthesia, surgery, or injections of medication for my child.

I give permission for my child’s picture to be used in future publications, including publication on PCC and its affiliates’ Web pages. I understand the registration fee is nonrefundable (if 60 days or less until camp) and nontransferable.

Campers who use tobacco, alcohol, or any form of illegal drugs will be dismissed. Any noncooperative or noncompliant campers will be subject to dismissal.

   
Signature – Parent or legal guardian only Date

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