Guest Group Medical Form

Run Your Own Camp

Medical & Liability Release Form
Member ID
A PARENT OR GUARDIAN MUST COMPLETE FORM FOR EACH MINOR.

Each attendee must turn in a seperate Medical Form.
Church/Group Name: *
Camp Date of Arrival:

MonthDayYear
Date
Camper Name: *
Gender*

MaleFemale
Birthdate*

MonthDayYear
Are you?*

A PARENT OR LEGAL GUARDIAN completing this form for a minorAn ADULT who will be attending camp

Parent or Guardian Information
Parent/Guardian*

First NameLast Name
E-mail*
Cell Number *
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact
Name of Emergency Contact*

First NameLast Name
Phone Number
Health Insurance & Medical Information
Health Insurance Carrier and policy number*
If the camper has no health insurance, enter NONE
Does your child have any food, medication or environmental allergies?*

YesNone
Allergies? Check all that apply*

FoodMedicationEnvironmentalNone
Please LIST ALLERGIES INDIVIDUALLY & EXPLAIN below*

PLEASE PROVIDE TYPCAL REACTION TO ALLERGEN0/150
Does your child have a special health or medical condition?*

YesNone
LIST ALL CONDITIONS AND ANY RESTRICTIONS BELOW*
Is there anything else we need to know*

0/200

PLEASE READ AND SIGN

Camper insurance begins where individuals health and accident insurance policy terminates. It is only valid when other insurance has been extended to its limits. In case of no personal policy, Ponderosa Pines’ policy will provide coverage within its limits for accidents only ($1000 per injury).

In case of emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child/the camper as named above. It is understood that the camp and doctor will make every effort to contact the parent/guardian of the child before treatment.

PHOTOGRAPHY: Registering for camp gives Ponderosa Pines permission to use your child’s likeness in print, video or on the internet for promotional purposes.
OFF-SITE TRANSPORTATION: Registering for camp gives Ponderosa Pines permission to transport your child to off-site activities if applicable.
DISCIPLINE POLICY: I understand that my child comes under the authority and reasonable guidelines of Ponderosa Pines and may be sent home in the event of a violation of the rules. If this should occur, I agree to come and get my child immediately.
Please check if you have read the above terms and agree to them.*

I have read and agree to the terms and conditions
PARTICIPATION, RELEASE, WAIVER & INDEMNITY AGREEMENT

WHILE PONDEROSA PINES CHRISTIAN CAMP MAKES EVERY EFFORT TO PROVIDE A SAFE AND PLEASANT ENVIRONMENT FOR YOUR CHILD, WE DO REQUIRE THAT THIS PARTICIPATION AGREEMENT BE READ, FILLED OUT, SIGNED AND DATED BY THE PARENT OR LEGAL GUARDIAN OF EACH CHILD UNDER 18 YEARS OF AGE WHO WISHES TO PARTICIPATE IN THE ACTVITIES WHICH OCCUR AT PONDEROSA PINES.

I, the undersigned, give permission the aforementioned camper to participate in the activities that occur at Ponderosa Pines Christian Camp, and on our around Ponderosa Pines. These activities include, but are not limited to, swimming in the pool, hiking, climbing, archery, disc golf, tetherball, horse shoes and strenuous competition games. I grant this permission with full knowledge that I accept full responsibility for any injury or accident that may occur.

Although Ponderosa Pines Christian Camp has taken reasonable steps to provide equipment and skilled employees so your child can participate in activities for which he/she may not be skilled in, we now remind you that these activities are not without risk. Certain risks cannot be eliminated due to the camp’s rural setting and without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury, illness or in extreme cases, permanent trauma or death. We do not want to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to be informed and know in advance about the inherent risks.

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Ponderosa Pines Christian Camp, Inc., its officers, Board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my child’s participation in any activity occurring at Ponderosa Pines Christian Camp, or on or around Ponderosa Pines. This release does not apply to intentional and/or willful acts of misconduct by Ponderosa Pines Christian Camp or any of it’s officers, Board, agents or employees.

Should Ponderosa Pines Christian Camp or anyone acting on their behalf, be required to incur attorneys’ fees and costs to enforce this agreement, I agree to indemnify and hold Ponderosa Pines Christian Camp harmless for all such fees an costs.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my child’s participation in these activities, I and/or my child my be found by a court of law to have waived any right to maintain a lawsuit against Ponderosa Pines Christian Camp on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it and agree to be bound by its terms.

SIGNATURE:_______________________________________________
Please check if you have read the above terms and agree to them.*

I have read and agree to the terms and conditions
Sign Document*
If you would like to print the form for your records, please do so before submitting.
Should be Empty:

Run Your Own Camp

Parent or Guardian Information

Emergency Contact

Health Insurance & Medical Information