HGXF Student Leaders

HGXF Student Leader Application
Participant Name*

First NameLast Name
Name for Name Tag
First Name Only
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Gender*

FemaleMale
Current Grade*
Must be 17 years old by June 1
Parish*
T-Shirt Size*

SmallMediumLargeX-Large2X-Large3X-Large
Parent/Guardian*

First NameLast Name
Phone Number*
Parent/Guardian E-mail*
example@example.com

Emergency Medical/Permission Form

Higher Ground Retreats™
I/We, as the parents/legal guardian of the above-named participant, a minor, hereby grant the Diocese of Grand Island, their staff, and volunteers permission to transport this minor to an emergency medical or health care facility for immediate treatment and/or consultation, if deemed necessary. I/We understand that I/we will be notified of any emergency situation immediately. I/We give authorization to the attending physician, dentist, or medical personnel for any required immediate treatment in the event that I/we cannot be reached at the time of the emergency. I/We agree to be financially responsible for any and all medical expenses and/or treatment costs and all related services provided to the above mentioned minor, and I/We release the Diocese of Grand Island, their staff, and volunteers from any liability.

I/We understand that this event is sponsored by the Diocese of Grand Island. I/We hereby grant permission for My/Our son/daughter to participate in Higher Ground Retreats™and accept full responsibility for any legal or financial consequences which may result from any personal actions (ie. damage to property or other participants/staff/volunteers) taken by My/Our son/daughter, and I/We agree to hold the Diocese of Grand Island, their staff, and volunteers harmless with respect to any actions or claims that may be made in connection with personal actions taken by My/Our son/daughter. I/We also grant permission for the Diocese of Grand Island, their staff, and volunteers to use photos and videos of My/Our son/daughter for publicity/marketing purposes.

I/We authorize the release of information to My/Our insurance company and family physician:
Insurance Company Name*
Phone Number*
Policy Number*
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physician's Name*
Physician's Phone Number*
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This minor has the following ALLERGIES:*
(including food allergies)
This minor has the following MEDICAL CONDITIONS:*
(including mental health or pregnancy)
This minor is currently taking the following MEDICATIONS:*
Please indicate:*

I prefer that she/he be responsible for these medications her/himself.I prefer that the staff hold these medications and dispense according to the directions.
Date of last Tetanus Shot*

MonthDayYear
Date
Please indicate:*

I DO give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment.I DO NOT give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment.
If other than above Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Number

Code of Conduct

Higher Ground Retreats™
Higher Ground Retreats™ are a five-day Catholic youth program. This program is sponsored by the Diocese of Grand Island, Office of Youth and Young Adult Ministry with Eric Heckman as Diocesan Director. The purpose of Higher Ground Retreats™ is to create an environment where Christian community may be experienced. The activities provide an enjoyable opportunity for young people to develop a better sense of self, to build positive relationships with others and to grow closer to God.

Code of Conduct
To accomplish the purpose of Higher Ground Retreats™, everyone on the week must agree to a “Code of Conduct.” These guidelines are necessary to make the stay enjoyable for all and to avoid problems. Participants have a responsibility to themselves and others to follow these guidelines:
- Be Respectful and Safe. At Higher Ground, we expect to create an environment of safety and trust. The use of our bodies, language, and humor must always honor the dignity of every person. If you jeopardize the physical or emotional safety of yourself or the group, you choose to have a parent or guardian pick you up and take you home immediately.
- Be Responsible and Honest. Participants are expected to be present at all activities on time and participate fully. Established guidelines will be observed at all times. We need to take care of the building and grounds. Any damage is to be reported immediately and involved persons are financially accountable. Emergencies that involve the health and well-being of people and/or property must be reported to adult staff immediately.
- The use of illegal drugs, including alcohol, or other illegal/harmful substances is not permitted. If you use these materials, you choose to have a parent or guardian pick you up and take you home immediately. Proper authorities will be notified. Do not bring clothing that advertises/promotes alcohol, tobacco or drug use or anything displaying messages that are offensive or contain sexual innuendo. These are contrary to the values of a Catholic youth camp and are not acceptable at Higher Ground.
- Observe appropriate boundaries. All participants must stay in designated areas. Vehicles can only be used with specific permission from the director. Males and females are lodged in dormitories with separate rooms. Participants do not enter each other’s rooms unless supervised by an adult. One of our goals is to relate with everyone present; therefore, during the week exclusive relationships are discouraged. If you engage in activities contrary to these guidelines or any activities that jeopardize your safety or the safety of the group, you choose to be removed from the event. Your parent or guardian will be called to pick you up and take you home immediately.
Dress Code
In order to promote a safe, healthy and positive community experience the following dress code must be followed by all male and female participants and adult leaders. Clothing should be modest and appropriate to a youth retreat/conference setting. Clothing should not present messages contrary to the values of a Catholic youth program.
- All attire should be sized to fit without exposing undergarments, buttocks, stomachs or cleavage.
- Shirts must be long enough to naturally touch the top of the lower garment, with arms raised.  Shirts must cover the shoulders. No Spaghetti straps, tank tops, and halter tops or transparent/mesh clothing or shirts with revealing necklines or armholes.
- Shorts and skirts must be fingertip length when arms are resting at sides.
- No yoga pants or form-fitting pants/shorts.
- No clothing or accessories that promote drugs, alcohol or tobacco either by brand or message.
- No clothing or accessories with sexually suggestive language or messages or clothing or accessories that promote violence, criminal activity, intimidation or intolerance of others (based on religion, ethnicity, gender or lifestyle).
- Modest swimsuit appropriate for a Catholic retreat setting, No Speedo or bikini.
Parent / Participant Signature:

I/We understand and accept the guidelines and policies stated in this Code of Conduct. I will accept the consequences should my son/daughter choose to violate the code. I agree to come to the retreat and pick up my son/daughter, should he/she choose to behave in a manner that the director and staff judge to be a serious violation of this code and is contrary to the mission of Higher Ground.
Parent/Guardian Signature*

Clear
Participant Signature*

Clear
Date

MonthDayYear
Date

Waiver of Liability/ Hold Harmless Release Form

Maranatha Camp & Retreat Center
Adult & Children Participant Release & Waiver of Liability, and Indemnity Agreement

PLEASE READ CAREFULLY. THIS DOCUMENT affects YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING MARANATHA BIBLE CAMP & RETREAT CENTER FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS, THEREFORE.

Assumption of Risk
I acknowledge and agree that any use of Maranatha Bible Camp and Retreat Center’s facilities, services, equipment, and premises (“Facilities”) and any participation in Maranatha Bible Camp & Retreat Center’s programs and activities (“Programs”) comes with inherent risks including, but in no way limited to (1) moderate and severe personal injury, (2) property damage, (3) disability,(4) death, and (5) sickness or disease. I voluntarily accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document.

Waiver, Release, Indemnification & Covenant Not to Sue
In consideration of the use of Facilities and participation in Programs I, the undersigned, agree that Maranatha Bible Camp & Retreat Center, it’s officers, directors, agents, employees, volunteers, insurers, and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by myself, my family members, dependents, or guests, including minors, however occurring including, but not limited to the negligence of Releasees. I understand that I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness, or disease sustained from the use of Facilities and participation in Programs.

I further agree, on behalf of myself and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which I and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, diseases or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however, the injury or damage occurs, including, but not limited to the negligence of Releasees.

In further consideration of the use of Facilities and participation in Programs, I agree to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities, or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs by myself, my family members, dependents or guests, including any minors.

Media Release

I understand that Maranatha Bible Camp reserves the right to use any audio, video, and/or photographs of any camper, guest, or staff member participating in any Maranatha facilitated event for promotional or marketing purposes. I have read and understood the Media Release as outlined above.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

HGXF Student Leader Application

Emergency Medical/Permission Form

Code of Conduct

Waiver of Liability/ Hold Harmless Release Form