• Medical Disclosure Form - YouthCamp 2024

    Covenant Fellowship Church
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    • Address & contact information 
    • Emergency Contacts 

    • We will call when there is a question about your child's health and/or in an emergency. Provide contact information for a custodial parent who will be available via phone while your child is attending camp.

    • Allergies 

    • If your child does not have any allergies this section can be left blank

    • Food Allergy/Epi-pen Forms: Please print out this form (2 pages). There is a section to be completed by your child's doctor, and by you as the parent. Completed forms can be mailed to dropped off at the church office attn: YouthCamp, or given to the camp nurse, Betsy Bittner.

    • Asthma? 

    • Asthma Forms: Please print out this form (1 page) there are pages that your child's doctor will need to complete as well as you, the parent. Completed forms can be mailed to dropped off at the church office attn: YouthCamp, or given to the camp nurse, Betsy Bittner.

    • Other Medical Information 
    • Current Medications 

    • Please list all mediations (including over-the-counter or nonprescrption drugs) being taken regularly. Bring enough medication to last the entire week of camp. Please plan on turing in all medications to the camp nurse when you check-in at YouthCamp. The camp nurse will hold and distribute all medications. Please keep the medications in original package or bottle.

    • Medication Authorization: If your child will take any medications while at camp please print out this form (1 page). There is a section to be completed by your child's doctor, and by you as the parent. Completed forms can be mailed to dropped off at the church office attn: YouthCamp, or given to the camp nurse, Betsy Bittner.

    • Health History  

    • Check conditions and describe below, list the year for each illness

    • Camp participation 

  • By signing below, I acknowledge that I have completed this Medical Disclosure Form accurately, truthfully and to the best of my knowledge. I further warrant and represent that if any of the information contained in this form changes at any time, I will immediatley provide Covenant Fellowship Church with such updated information. I acknowledge that the program will handle medications as described and that information on this form will be shared with staff on a need-to-know basis.

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  • Parent or Guardian endorsement required in participant is under the age of eighteen (18):

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  • Participant release/waiver of liability and indemnification agreement

    Covenant Fellowship Church - YouthCamp 2023

  • ...who is under 18 years old.  In consideration for my child’s opportunity to participate in the YouthCamp (“YC”) of Covenant Fellowship Church, Inc. (“CFC”), to be held August 13-16, 2024, I affirm and agree with the following statements:

    1. I voluntarily agree to allow my child to participate in YC, and expressly assume any and all dangers, hazards, and risks associated with my child’s participation in YC, including, but not limited to, illness, injury, and/or death due to:

    • Accidents during travel to and from YC and during YC,
    • Insect and other animal bites, exposure to the elements, forces of nature (including lightning strikes),
    • Other natural and accidental causes 

    2. My child is physically sound and suffering from no condition, impairment, disease, or other illness that would hinder me or others from safely participating in YC.  It is my responsibility to ensure that my child follows any restrictions, prescriptions, or limitations that apply to my child’s physical condition or state of fitness.

    3. I understand that my child’s participation in YC includes physical activity that requires strength, flexibility, and/or stamina, and that my child could become injured while participating in such activity, especially if he/she exceeds the limits that his/her body is capable of accepting, executing, and/or performing. 

    4. I recognize and fully understand and agree that in the event it becomes necessary for my child to receive medical treatment during his/her participation in YC, reasonable efforts will be made to contact the persons listed on my child’s Medical Disclosure Form to obtain directions and authorization for such treatment.  However, if the person(s) listed cannot be reached, I hereby authorize, direct, and give my full and complete permission to one or more authorized representatives of CFC and/or any  employees, volunteers, representatives, or agents (collectively, “Agents”) to seek medical treatment on my child’s behalf, including selecting and authorizing medical professional(s) (including, but not limited to nurses, LPNs, PAs, paramedics, doctors, or dentists) to take such action as is deemed necessary by any attending medical professional.  I further give my full and complete authorization to such medical professional to hospitalize, order injections, administer anesthesia, perform surgery, or secure additional necessary medical treatment for my child as necessary and/or appropriate under the circumstances as determined by the medical professional.  I further certify that I am willing to assume the risk of any medical or physical condition that my child may have.  I further understand and acknowledge that it is my duty to provide accurate and current information of such conditions on my child’s Medical Disclosure Form.

    I recognize and fully understand that the insurance coverage listed on my child’s Medical Disclosure Form will be used as the sole insurance coverage for him/her in the event medical treatment is needed, and that I (or the responsible party for my insurance coverage) am solely and personally responsible for any payments or charge(s) not covered by such insurance.  I further understand, acknowledge, and agree that no such insurance coverage is or will be provided for me by CFC.  I understand and agree that if my child does not currently have valid health insurance coverage, none will be provided for him/her by CFC, and that I (or the responsible party for my insurance coverage) am responsible for any and all costs associated with medical treatment that may be required as a result of my participation in YC.

    5. My child and I agree to become familiar with all YC rules and instructions and to abide by them.  I understand that CFC retains the right to suspend or terminate my child’s participation in YC if it believes that I have failed to comply with any Activity rules or instructions, or for any other reason in its sole discretion.


    6. Except where such an exception is prohibited or limited by applicable law, except for any claims, actions, liability, and/or demands (“Claims”) that arise from, are caused by, or result from the gross negligence or willful misconduct of CFC and its affiliates, subsidiaries, directors, employees, volunteers, independent contractors, agents, assignees, representatives and successors in interest (collectively, “Affiliates”), I hereby release, forever discharge, and agree to hold harmless CFC and its Affiliates from any and all Claims for bodily injury, property damage, wrongful death, loss of services, or otherwise, which may arise out of the my child’s participation in YC or which may arise out of my child’s travel to or participation in and returning from any activity associated with YC, which may hereafter accrue to my child or me against CFC and/or its Affiliates.  This Release/Waiver is understood to also be in effect with respect to, and to include any persons who may be engaged in, the transportation, treatment or attending to, or accompanying my child to any facility for Medical Treatment on or off of YC property, on the same basis and terms as stated above.  I further agree to hold harmless and indemnify CFC and its Affiliates from any Claims resulting in any way from my child’s or my acts or omissions.

    7. I hereby give CFC and its Affiliates the irrevocable right to copy, display, publish, or otherwise use my child’s image in any form of media that now exists or may exist in the future, and give others permission to copy, display, publish, or otherwise use my child’s image, so long as CFC and/or its Affiliates determine that doing so supports or benefits CFC’s mission.

    8. I agree that any dispute that I may have with CFC and/or its Affiliates regarding my child’s participation in YC and/or this Release/Waiver shall be settled only by mediation, or, if necessary, legally binding arbitration in accordance with the Rules of Procedure of the Institute for Christian Conciliation of Peacemaker Ministries, www.peacemaker.net.  I understand that the decision and/or award of an arbitrator may be entered in any court otherwise having jurisdiction and that such a decision and/or award shall be the sole remedy to any dispute and is non-appealable. 

    9. If any provision or clause of this, or any portion thereof, shall be held by any court or other tribunal of competent jurisdiction to be illegal, void, or unenforceable in such jurisdiction, the remainder of such provisions shall not thereby be affected and shall be given full effect, without regard to the invalid portion.  It is the intention of the parties that, if any court or other tribunal of competent jurisdiction construes any provision or clause of this Release/Waiver, or any portion thereof, to be illegal, void, or unenforceable because of the extent or duration of such provision or the matter covered thereby, such court or tribunal shall reduce the extent, duration, or matter of such provision, and, in its reduced form, such provision shall then be enforceable and shall be enforced.

    10. Should any provision of this Release/Waiver be held to be void, invalid or inoperative, the remaining provisions of this Release/Waiver shall not be affected and shall continue in effect and the invalid provision shall be deemed modified to the least degree necessary to remedy such invalidity.

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