Mid-Atlantic Teen Retreat

I, the undersigned parent or guardian, hereby consent to my child participating in the Mid-Atlantic Teen Retreat at Calvary Baptist Church in Roanoke Rapids, NC, on July 16-19, 2024. I understand that this retreat will include bus rides, church services, indoor gym activities, activities at Top Golf, and activities at Kings Dominion that could result in injuries or death. I certify that my child is able to participate in any and all of these activities. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. If I cannot be reached within a reasonable period of time, as determined by church officials, I hereby authorize the church or the adult sponsor, Nathan Johnson to make emergency medical decisions for my child. If there are any activities that I do not want my child to be involved in, I have listed them below.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO. I do, for myself and for my child, heirs and assigns, hereby irrevocably and unconditionally release, acquit and forever discharge Victory Baptist Church and its agents, companies used, employees, and volunteers from any and all liability, actions, causes of actions, claims, expenses, obligations, and damages of any nature whatsoever, which I now have or which may arise in the future, in connection with my child’s participation in the described activity or in any other associated activities including, but not limited to, any injury to my child or property, even injury resulting in death.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of North Carolina, and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I expressly agree that any dispute arising from this activity shall be submitted to binding arbitration, to the extent it is not covered by insurance. This release contains the entire agreement between the parties hereto.

I further state that I HAVE CAREFULLY READ AND UNDERSTAND THE FOREGOING RELEASE AND KNOW THE CONTENTS HEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. I understand that this is a legally binding agreement.

Medical conditions to be aware of: *

Physical restrictions to be aware of: *

Please list any medications and instructions:

Please list any food allergies or restrictions the camp needs to be aware of:

Date of last tetanus booster:

I do NOT wish my child to participate in the following:

Name of Minor*

First NameLast Name

Age of Minor*

Name of Parent/Guardian*

First NameLast Name

Phone Number in Case of Emergency*

Please enter a valid phone number.

Parent/Guardian Signature*

Date