Summer Camp Parental Consent

Youth Camp 2022 Bible Baptist Church

Permission to Participate - Authorization for Medical Treatment - Release & Liability
General Information
Participant's Full Name *

First Name Last Name
Participant's Birth Date *

Month Day Year
Date
Participant Cell Number
Parent/Guardian Information
Parent/Guardian Full Name *

First Name Last Name
Cell Number *
Please enter a valid phone number.
Work Phone
Parent Email *
example@example.com
Parent/Guardian Full Name

First Name Last Name
Cell Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Additional Info

0/90
Medical Information
Medical Insurance Company *
Insurance Policy Number *
Any food, medical, or environmental allergies? *
List any Medical Problems (asthma, seizures, headaches): *
Significant Medical History (surgery, injuries, serious illness) *
Is any medication required? *

Yes No
If yes, list any medications taken regularly and directions:
Blood type:
Authorization for Medical Treatment

Please read and sign below in agreement.
I am the parent or legal guardian of PARTICIPANT named above (hereinafter "my child"). My child is attending and participating in activities at CACHUMA LAKE. (hereinafter "this camp," "church," "school," etc.) located at: 1 Lakewood Dr., Santa Barbar, CA 93105 beginning on the day of June 27, 2022.

I hereby authorize the CAMP DIRECTOR Pastor Luis Parada and YOUTH LEADER Ronnie Reynoso and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child under Sections 6901, 6902, and 6910 of the California Family Code.

The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child.

I further authorize the CAMP DIRECTOR and YOUTH LEADER and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this CAMP to receive physical custody of my child, under Section 1283 (a) of the California Health and Safety Code, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the CAMP DIRECTOR and his/her officers, agents, servants, or employees that are 18 years of age or older who supervise the activities at this CAMP.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.
Please Print Name of Parent/Guardian and sign below for medical authorization *

First Name Last Name
Signature for authorization for medical treatment *

Clear
Emergency Contacts (if parent/guardian cannot be reached)
If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.
Emergency Contact #1 Name *

First Name Last Name
Relationship *
E-mail *
example@example.com
Cell Phone Number *
Release and Liability
IT IS THE INTENTION OF PARENT/GUARDIAN OF PARTICIPANT BY THIS AGREEMENT TO EXEMPT AND RELIEVE BIBLE BAPTIST CHURCH OF LONG BEACH AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF PARTICIPANT NAMED ABOVE CAUSED BY ANY ACT OF NEGLIGENCE OF BIBLE BAPTIST CHURCH OF LONG BEACH AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES.

For and in consideration of permitting PARTICIPANT to observe, or use any facility or equipment of BIBLE BAPTIST CHURCH OF LONG BEACH or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: CACHUMA LAKE in the city of Santa Barbara, State of California, beginning on the day of June 27, 2022, the undersigned parent and/or guardian of PARTICIPANT: hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to PARTICIPANT as a result of PARTICIPANT observing or using facilities or equipment of BIBLE BAPTIST CHURCH OF LONG BEACH or engaging in or receiving instructions in any activities or related transportation SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue.

The undersigned parent or guardian of PARTICIPANT for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against BIBLE BAPTIST CHURCH OF LONG BEACH or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless BIBLE BAPTIST CHURCH OF LONG BEACH and its officers, agents, servants, or employees from any and all claims or causes of action by PARTICIPANT or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of PARTICIPANT present any claim against BIBLE BAPTIST CHURCH OF LONG BEACH and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by BIBLE BAPTIST CHURCH OF LONG BEACH and said persons.

The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.I release and waive, and further agree to indemnify, hold harmless or reimburse Bible Baptist Church of Long Beach, the individual members, agents, employees and representatives thereof, as well as activity supervisors, from and against, any claim which I, any other parent or guardian, any sibling, the above-named child, or any other person, firm or corporation may have or claim to have, known or unknown, directly or indirectly, for any losses, damages or injuries arising out of, during, or in connection with the child's participation in the activities (including all forms of transportation) or the rendering of emergency medical procedures or treatment, if any.
Print Name of Parent/Guardian and Sign in agreement to Release/Waiver *

First Name Last Name
Signature of Release/Waiver *

Clear
Requirements
The child named above is in good health and has no physical or medical limitations that would prohibit your child from participating in the meals, activities, church services, and any other gatherings. Parents/guardians should specify allergies and medical problems in section above.
Transportation
Participants will be transported from Bible Baptist Church via school bus to Cachuma Lake.

Drop Off (Bible Baptist Church) - Monday, June 27, 7:00 am

Pick Up (Bible Baptist Church) - Friday, July 1, 6:00 pm
Consent
I hereby attest that I am (we are) the legal parentguardian(s) of the above-named child and hereby consent to the child's participation in the activities described above. I understand that activities of the kind described above may result in physical injury to my child but nonetheless specifically request that he or she be allowed to participate in those activities.
Insurance
I/We understand that Bible Baptist Church of Long Beach, does not carry any insurance relative to the activities or for any injury that may occur to the above-named child. I/We represent that the child is (a) covered by insurance through my own insurance carrier; or (b) that I/We am personally financially responsible for any and all medical costs incurred as a result of the child's injury.
PLEASE CLICK AGREE AND SIGN BELOW IN AGREEMENT
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions. *

I agree
Date *

Month Day Year
Date
Print Name of Parent / Guardian and sign below in agreement *

First Name Last Name
Signature *

Clear
Should be Empty:

Youth Camp 2022 Bible Baptist Church

General Information

Parent/Guardian Information

Medical Information

Authorization for Medical Treatment

Emergency Contacts (if parent/guardian cannot be reached)

Release and Liability

Requirements

Transportation

Consent

Insurance

PLEASE CLICK AGREE AND SIGN BELOW IN AGREEMENT