2023 LAFILNAZ Family Camp Waiver Form

LAFILNAZ 2023 Family Camp

Waiver Form
If you are under 18, please have a parent or guardian sign the form. Make sure you sign the form per person, not per family.
Camper Name:*

First NameLast Name
Gender*

MaleFemale
Birthday*

MonthDayYear
Date
Age
Email*
example@example.com
Does any one have allergies?*

YesNoIf Yes please type here
If you answered "Yes" above please specify. *
Any prescribed medicine or illness we need to be aware of?*
T-Shirt Size*

SMLXL2XL
Have you paid for the camp? (For your spot to be saved you must place a small deposit; Please see Sis. Girly for payment options)*

Yes (Paid in full!)Yes (Payment Plan)No
Will you need a ride to camp?*

YesNo
Will you have space in your car (if and only you are driving)*

YesNoNA (Not Applicable)
If you answered "Yes," how many spots in your car?*
Any questions about transportation arrangement?*
Who is your preferred roommate? (Note: Depending on available space, you may or may not be with your preferred roommate. We will do our best to meet your preference).
Emergency Contact Information

Please enter the name of parent or guardian who should be contacted in case of an emergency.
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
E-mail Address*
example@example.com
Relationship:*

SiblingParentChildFriendOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Informed Consent and Acknowledgement I hereby give my approval for the camper's participation in any and all activities prepared by L.A. First Filipino Church of the Nazarene (LAFILNAZ) during the selected camp. In exchange for the acceptance of said person's candidacy by LAFILNAZ, I assume all risks and hazards incidental to the conduct of the activities, and release, absolve and hold harmless LAFILNAZ, and all its respective officers, agents, and representatives from any and all liability for injuries to a said person arising out of travelling to, participating in, or returning from selected camp sessions. In case of injury to said person, I hereby waive all claims against LAFILNAZ. Including all volunteers, church staff, all participants and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all camp activities. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization As the named camper or Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the camper, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to LAFILNAZ. and its affiliates including Church Staff and volunteers to provide the needed emergency treatment prior to the camper's admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named camper, in my absence.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE. Signature*
Should be Empty:

LAFILNAZ 2023 Family Camp

Emergency Contact Information