penndelyouth Winter Retreat 2025

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STUDENT NAME:* This field is required.
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7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
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GENDER AT BIRTH:* This field is required.
MALE
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STUDENT BIRTHDATE:* This field is required.
Date
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NAME OF CHURCH STUDENT IS ATTENDING WINTER RETREAT WITH:* This field is required.
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Abundant Life Assembly of God, Altoona, PA
Abundant Life Assembly of God, Bradford, PA
Abundant Life Assembly of God, Birdsboro, PA
Agape Assembly of God, Saint Marys, PA
All Nations Church, Bear, DE
Allison Park Church - Butler Campus, Butler, PA
Allison Park Church North Side, Pittsburgh, PA
Allison Park Church of the AG, Allison Park, PA
Alpha Assembly of God, Clarion, PA
Anchor Church, Milford, DE
Anita Assembly of God, Anita, PA
Antrim Assembly of God, Greencastle, PA
Assembly of God, Albion, PA
Assembly of God, Bristol, PA
Assembly of God, Duncannon, PA
Assembly of God, Jeannette, PA
Assembly of God, Kantner, PA
Assembly of God, Lewistown, PA
Assembly of God, Mifflinburg, PA
Assembly of God, Dalton, PA
Assembly of God, Millersburg, PA
Assembly of God, Monroeville, PA
Assembly of God, Newport, PA
Assembly of God, New Stanton, PA
Assembly of God, Northampton, PA
Assembly of God, Blakely, PA
Assembly of God, Shanksville, PA
Assembly of God, Shrewsbury, PA
Assembly of God, State College, PA
Assembly of God, Towanda, PA
Assembly of God, Tunkhannock, PA
Assembly of God, Valley Grove, WV
Assembly of God, Windsor, PA
Assembly of God, Wrightsville, PA
Assembly of God, Clarks Green, PA
Assembly of God, Saint Thomas, PA
Awesome Faith Christian Center, Philadelphia, PA
Back Mountain Harvest Assembly, Trucksville, PA
Barclay Assembly of God, Barclay, MD
Beaver Assembly of God, Beaver, PA
Benton Assembly of God, Stillwater, PA
Berwick Assembly of God, Berwick, PA
Beth Emanuel Assembly of God, Philadelphia, PA
Bethel Assembly, Carlisle, PA
Bethel Assembly, Pittsburgh, PA
Bethel Assembly of God, Catawissa, PA
Bethel Assembly of God, Girard, PA
Bethel Assembly of God, Littlestown, PA
Bethel Assembly of God, Chambersburg, PA
Bethlehem Assembly of God, Darby, PA
Blue Mountain Assembly of God, Newburg, PA
Bread of Life Assembly of God, Upper Darby, PA
Breezewood Lighthouse Assembly of God, Breezewood, PA
Bridge Community Church, Lansdale, PA
BridgePoint Church, Tarentum, PA
Brookline Assembly of God, Pittsburgh, PA
Butler Assembly of God, Butler, PA
Butler City Church, Butler, PA
Calvary Assembly of God, Dover, DE
Calvary Assembly of God, Wilmington, DE
Calvary Assembly of God, Connellsville, PA
Calvary Assembly of God, Waynesboro, PA
Calvary Assembly of God, Wyncote, PA
Calvary Christian Center, Pottstown, PA
Calvary Church of the Assemblies of God, Irwin, PA
Calvary Full Gospel Church, Bridgeville, PA
Calvary Temple, York, PA
Capital City Church Assembly of God, Harrisburg, PA
Captivate Community Church, Hanover, PA
Celebration Community Church, Dillsburg, PA
Central Assembly of God, Bethlehem, PA
Central Assembly of God, Houston, PA
Central Bucks Christian Fellowship, Pipersville, PA
CHANGE Community Church, Philadelphia, PA
Chapel on the Hill Assembly of God, Emlenton, PA
Chester Springs Community Church, Chester Springs, PA
Christ Center Assembly of God, Pittsburgh, PA
Christian Assembly of God, Bentleyville, PA
Christian Life Assembly, Camp Hill, PA
Christian Life Assembly, Melcroft, PA
Christian Life Assembly, Stroudsburg, PA
Christian Life Center Assembly of God, Bensalem, PA
Christian Life Church, Chambersburg, PA
Christian Life Church, Trafford, PA
Christlife Pentecostal Church, Lancaster, PA
Church of the New Covenant, Mansfield, PA
Church of the New Testament, Hagerstown, MD
City Limits Assembly of God, Allentown, PA
City Reach Church - Kensington, Philadelphia, PA
City Reach Church - Philadelphia East, Philadelphia, PA
City Reach Church - Reading, Reading, PA
CityLife Church, Philadelphia, PA
CityLife Southwest, Philadelphia, PA
Confident Life Assembly, Scranton, PA
Connect Church of Bedford County, Alum Bank, PA
Connection Church Assembly of God, Pottstown, PA
Cornerstone Assembly of God, Boynton, PA
Cornerstone Assembly of God, Kittanning, PA
Cornerstone Christian Fellowship, Abington, PA
Cornerstone Fellowship Assembly of God, Wormleysburg, PA
Cranberry Community Church of the A/G, Franklin, PA
Cross Road AG, Elmhurst Township, PA
Cross Valley Assembly of God, Forty Fort, PA
Crosspoint Assembly of God, Carmichaels, PA
Crosspoint Waynesburg, Carmichaels, PA
Crossroads Community Church, Mechanicsburg, PA
Crossroads Community Church, Fogelsville, PA
Crossroads Family Worship Center, Wellsboro, PA
CrossWay Community Church, Valencia, PA
Danville Assembly of God, Riverside, PA
Deep Water Church, Wyoming, DE
Dover Assembly of God, Dover, PA
Dream Center Church, Monroeville, PA
Dream Center of Philadelphia, Philadelphia, PA
Eagle's Nest Assembly of God, Greenville, PA
Eagle's Wings Church, Pittsburgh, PA
East End Assembly of God, Pittsburgh, PA
East Erie Assembly of God, Erie, PA
Eastside Assembly of God, York, PA
Echo Hope Assembly, Mill Hall, PA
El Shaddai Assembly of God, Nazareth, PA
Emmanuel Assembly of God, Allentown, PA
Emmanuel Assembly of God, Harveys Lake, PA
Encounter Praize and Worship Center, Seaford, DE
Eternal Grace Church, West Chester, PA
Evangel Assembly of God, Glenolden, PA
Evangel Assembly of God, Mc Connellsburg, PA
Evangel Assembly of God, Norristown, PA
Evangel Heights Assembly of God, Sarver, PA
Everett Assembly of God, Everett, PA
Fair Ridge Pentecostal Assembly of God, Shade Gap, PA
Faith Assembly of God, Hazle Township, PA
Faith Assembly of God, New Cumberland, PA
Faith Assembly of God, Philadelphia, PA
Faith Assembly of God, Cressona, PA
Faith Assembly of God, Roaring Spring, PA
Faith Assembly of God, Uniontown, Pa
Faith Assembly of God - Belle Vernon, Uniontown, PA
Faith Church Nanticoke, Nanticoke, PA
Faith Church, Weatherly, Weatherly, PA
Faith Community Assembly of God, Easton, PA
Faith Dinner Church, New Cumberland, PA
Faith Outreach Center, Mount Joy, PA
Family Life Community Church, Bangor, PA
Family Life of Penns Valley, Centre Hall, PA
Family Worship Center, Lansdale, PA
Family Worship Center of Erie, Erie, PA
Family Worship Center of Red Lion, Red Lion, PA
Family Worship Center of the AG, New Kingstown, PA
First Assembly of God, Beaver Falls, PA
First Assembly of God, Waynesburg, PA
First Assembly of God, Columbia, PA
First Assembly of God, Greencastle, PA
First Assembly of God, Greentown, PA
First Assembly of God, Indiana, PA
First Assembly of God, Irwin, PA
First Assembly of God, Lancaster, PA
First Assembly of God, Meadville, PA
First Assembly of God, Mount Union, PA
First Assembly of God, New Castle, PA
First Assembly of God, Scottdale, PA
First Assembly of God, Shippensburg, PA
First Assembly of God, Tyrone, PA
First Assembly of God, Union City, PA
First Assembly of God, Wilkes Barre, PA
First Assembly of God, Windber, PA
First Assembly of God, Russell, PA
First Assembly of God, Erie, PA
First Assembly of God of Hermitage, Hermitage, PA
Forged in Faith Church, Inc, Russellton, PA
Freedom Life - Quarryville, Christiana, PA
Freedom Life Centre County Campus, Milesburg, PA
Freedom Life Christian Center, Christiana, PA
Freedom Life Church, Milton, PA
Freedom Life Coatesville Campus, Coatesville, PA
Freedom Path Church, Akron, PA
Freedom Valley Worship Ctr, Gettysburg, PA
Full Gospel Assembly of God, Indiana, PA
Gardner Chapel, New Castle, PA
Genesis Church, Moon Twp, PA
Glad Tidings Assembly of God, Bloomsburg, PA
Glad Tidings Assembly of God, Clearfield, PA
Glad Tidings Assembly of God, Mc Clellandtown, PA
Glad Tidings Assembly of God, Middletown, PA
Glad Tidings Assembly of God, Reading, PA
Glad Tidings Tabernacle Assembly of God, Hyndman, PA
Glendale Assembly of God, Coalport, PA
God Behind Bars - Somerset, Allison Park, PA
Gospel Tabernacle Assembly of God, Philipsburg, PA
Grace Assembly of God, Spring City, PA
Grace Assembly of God, Bethlehem, PA
Grace Assembly of God, Apollo, PA
Greater Valley Assembly of God, Athens, PA
Green Ridge Assembly of God, Scranton, PA
Greenwood Assembly of God, Fayetteville, PA
GT Church - Kutztown, Reading, PA
Hamlin Assembly of God, Lake Ariel, PA
Harbor of Hope Ministries Assembly, Mercer, PA
Harrisburg First Assembly of God, Harrisburg, PA
Harrisburg First Nepali Church of the AG, Harrisburg, PA
Harvest Church, Fleetwood, PA
Harvest Family Fellowship of the A/G, Liberty, PA
Harvest International Church, Philadelphia, PA
Harvest Worship Center Full Gospel, Downingtown, PA
Heritage Assembly of God, Gettysburg, PA
Higher Ground Assembly of God, Mt Pleasant Mills, PA
Highpoint Community Church, Ephrata, PA
HighPointe Church, Philadelphia, PA
Highway Mission Tabernacle, Philadelphia, PA
Hollentown Assembly of God, Fallentimber, PA
Hope Arabic Christian Church, Harrisburg, PA
Hope Communty Church, Altoona, PA
Hope Fellowship Assembly of God, Slippery Rock, PA
Hope Springs Church, Northern Cambria, PA
House of Joy, Philadelphia, PA
House of Refuge Assembly of God, Allentown, PA
Iglesia Cristiana Central, Houston, PA
Inglesia Fe, Hazleton, PA
Innovation Church, Cresco, PA
International Christian Fellowship, Darby, PA
Jersey Shore Assembly of God, Jersey Shore, PA
Journey Christian Church, Thompsontown, PA
Journey Church, Phoenixville, PA
Journey Church - Royersford, Phoenixville, PA
Journey Church of Phoenixville, Phoenixville, PA
Kensington Assembly of God, Philadelphia, PA
Kingdom Family Fellowship, Norristown, PA
King's Assembly of God, Wilmington, DE
Kinport Assembly of God, Cherry Tree, PA
Kiski Valley Community Church, Leechburg, PA
Lancaster City Assembly, Lancaster, PA
Liberty Worship Center, Fairfield, PA
Life Christian Fellowship A/G, Springfield, PA
Life Church of Hershey, Hershey, PA
Life Community Church, Dubois, PA
Life Connection Church, Palmyra, PA
Life Discovery Church, Mc Sherrystown, PA
Life In Christ Fellowship, Dillsburg, PA
LifeSpring Fellowship, Lititz, PA
LifeStone Church, Munhall, PA
Lighthouse A/G of New Holland, New Holland, PA
Lighthouse Assembly of God, Ellwood City, PA
Lighthouse City Church, Mckeesport, PA
Lighthouse Community Church of Mifflinto, Mifflintown, PA
Lighthouse Family Center, Philadelphia, PA
Living Hope Assembly of God, Clairton, PA
Living Water Christian Outreach, Three Springs, PA
Living Waters Chapel Assembly of God, Lebanon, PA
Living Way Church, Greensburg, PA
Lost & Found Christian Fllwshp W Hill, Aliquippa, PA
Lykens Valley House of Prayer, Lykens, PA
Main Line Assembly of God, Belmont Hills, PA
Manada Gap Full Gospel Mission, Harrisburg, PA
Manchester Assembly of God, Manchester, PA
McKees Rocks Assembly of God, Mc Kees Rocks, PA
Midway Assembly of God, Lewes, DE
Moosic Assembly of God, Moosic, PA
Morning Star Fellowship, Bechtelsville, PA
Morning Star Fellowship of Quakertown, Quakertown, PA
Morning Star Fellowship of Quakertown-Pennsburg, Pennsburg, PA
Mosaic Church, Reading, PA
Mount Jewett Assembly of God, Mount Jewett, PA
Mount Morris Gospel Tabernacle, Mount Morris, PA
Mountainside Assembly of God, Coal Township, PA
Mountaintop Family Church, Mountain Top, PA
Mt Laurel View Church, Mount Pleasant, PA
Navigate Church, Langhorne, PA
New Beginnings Assembly of God, Kane, PA
New Beginnings Church, Punxsutawney, PA
New Beginnings Church of Bucks County, Jamison, PA
New City Church of Wilmington, DE, Wilmington, DE
New Covenant Assembly of God, Montgomery, PA
New Creation Assembly of God, Sunbury, PA
New Culture Church, Pittsburgh, PA
New Day Assembly of God, Upper Saint Clair, PA
New Franklin Assembly of God, Chambersburg, PA
New Hope Assembly of God, Nu Mine, PA
New Hope Assembly of God, Elizabeth, PA
New Life Assembly of God, Corry, PA
New Life Assembly of God, Dunmore, PA
New Life Assembly of God, East Berlin, PA
New Life Assembly of God, Grantville, PA
New Life Assembly of God, Lancaster, PA
New Life Assembly of God, Landisburg, PA
New Life Assembly of God, Pottstown, PA
New Life Assembly of God, Friedens, PA
New Life Assembly of God, Tamaqua, PA
New Life Assembly of God, Altoona, PA
New Life Center Assembly of God, Ford City, PA
New Life Indian Church, Inc, Gibsonia, PA
New Life Praise Center, Philadelphia, PA
New Testament Assembly of God, Millville, PA
Newville Assembly of God, Newville, PA
North Boroughs Church, Inc, Allison Park, PA
Northeast Assembly of God, Philadelphia, PA
Oasis City Church, Philadelphia, PA
Orchard Beach Assembly, North East, PA
Orchard Springs Fellowship, Aspers, PA
Overbrook Assembly of God, Philadelphia, PA
Pakistani New Life Church, Philadelphia, PA
Parkview Assembly of God, Newark, DE
Parsonville Assembly of God, Houtzdale, PA
Pentecostal Tabernacle Assembly of God, Central City, PA
Philadelphia Christian Center, Bensalem, PA
Philadelphia India Assembly of God, Philadelphia, PA
Philadelphia Myanmar Community Church, Chester, PA
Philadelphia Shalem AG Church, Philadelphia, PA
Pinchot Park Assembly of God, Wellsville, PA
Pitcairn Assembly of God, Pitcairn, PA
Pleasant Valley Assembly of God, Brodheadsville, PA
Pocono Community Church, Tobyhanna, PA
Praise Assembly of God, Newark, DE
Praise Assembly of God, North Versailles, PA
Radiant Light Assembly of God, Muncy, PA
Real Church, Brookhaven, PA
Real Life Church, Arnold, PA
Real Life Church Assembly of God, Bedford, PA
Real Life Community Church, Middletown, DE
ReaLife Assembly of God, Erie, PA
Redemption International Ministries, York, PA
Rescue Community Church, Harrisburg, PA
Resurrection Life Church, Philadelphia, PA
Revival Church International, Allison Park, PA
Refuge Youth Network
Ridgewood Assembly of God, Pittsburgh, PA
River City Church AG, Glassport, PA
River of God Church, Enola, PA
River of Life Assembly of God, Sunbury, PA
River of Life Church of the AG, Doylestown, PA
Riverside Community Church, Oakmont, PA
Riverside Community Church/Tarentum, Oakmont, PA
Rock Full Gospel Assembly of God, Mifflin, PA
Rock Run Church, Muncy Valley, PA
Rohlers Assembly of God, Dover, PA
Selbyville Assembly of God, Selbyville, DE
Shalom Assembly of God, Warwick, PA
Shalom Worship Center- Phila, Philadelphia, PA
Sharpsburg Family Worship Center, Sharpsburg, PA
Shillington Assembly of God, Reading, PA
Solid Rock Revival Church, Oakdale, PA
South Butler Assembly of God, Butler, PA
South Hills Assembly of God, Bethel Park, PA
Spanish Emmanuel Church AG, Allentown, PA
Sparrow Fellowship, Waterford, PA
St John's Union Church, Mt Pleasant, PA
Story Collective Church, Allison Park, PA
Sunshine Full Gospel Assembly of God, Shickshinny, PA
The Block Church, Philadelphia, PA
The Bridge Church, Hamburg, PA
The Bridge Community Church of Nicholson, Nicholson, PA
The Church on the Hill, Kutztown, PA
The Dinner Table, Newport, PA
The Fold, Pittsburgh, PA
The Intersection, Gettysburg, PA
The Joy Center of Fountain Hill, Fountain Hill, PA
The Shepherd's House Ministries, Philadelphia, PA
Thrive Church, Cambridge, MD
Thrive Church of Peckville AG, Blakely, PA
Transform Church, Downingtown, PA
Transformation Church, Altoona, PA
Transformation Church, Grove City, PA
Tree of Life Assembly of God, Latrobe, PA
Tri-County Worship Center, Bethel, PA
Trinity Assembly of God, Huntingdon, PA
Trinity Assembly of God, Montoursville, PA
Trinity Assembly of God, West Chester, PA
Trinity Community Church, Hockessin, DE
Valley View Assembly of God, Knoxville, PA
Valley View Community Outreach, Yoe, PA
Verge Church, Collegeville, PA
Victory Christian Fellowship, Norristown, PA
Victory Christian Life Center, Pottstown, PA
Walnut Grove Assembly of God, West Mifflin, PA
Williamsport Assembly of God, Williamsport, PA
Zion Christian Church, Pittsburgh, PA
Zion Church of God, Blandon, PA
OTHER
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EMERGENCY CONTACT NAME: * This field is required.
First Name
Last Name
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EMERGENCY CONTACT PHONE NUMBER: * This field is required.
Please enter a valid phone number.
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EMERGENCY CONTACT EMAIL ADDRESS: * This field is required.
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INSURANCE INFO * This field is required.
Insurance Company:
Policy #:
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FRONT OF INSURANCE CARD:
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BACK OF INSURANCE CARD:
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DATE OF LAST TETANUS SHOT
Date
Month
Day
Year
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ALLERGIES
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MEDICATIONSPLEASE NOTE: **Our Medical Personnel can only dispense medications in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, and the dosage and frequency of administration. Please List ALL medications including over-the-counter or non-prescription drugs and vitamins) that are taken routinely. Send medication to last the entire duration of camp; no more, no less.
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MEDICATIONS CONTINUED* This field is required.I give permission for the on-site medical personnel to administer the following medications to my child when necessary:
Tylenol (Acetaminophen)
Advil (Ibuprofen)
Benadryl (Diphenhydramine)
Aspirin
Pep Bismol
Anti-Acid
Cough Drops
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PARENTAL PERMISSION & RELEASE FORM* This field is required.CONSENT AND RELEASE OF LIABILITY This application and any health history provided herein are correct and complete. I authorize any minor child of mine herein named to engage in all activities and events, except as expressly noted. I authorize Penn-Del Ministry Network (“Penn-Del”) and any of its volunteers, employees, or affiliate churches, their volunteers, or employees to provide for any routine health care, administration of prescribed medications, and emergency treatment for me or my child, as may be deemed reasonable, within the sole discretion of Penn-Del, including but not limited to, x-rays, medical tests, treatment, or hospitalization. I agree to release to Penn-Del any medical or billing records necessary for treatment referral, billing, or insurance purposes. I acknowledge and consent that Penn-Del, its affiliates and vendors may take photographs and video images of me or my child during any event for use in advertising or any other purpose, including but not limited to, brochures, videos, and for use on the internet. I acknowledge that participation in the activities and events named or described above involve risk to me and my child, and may result in various types of injury, including but not limited to, sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activities and events named or described above, I, for me and my child, assume the risks of injury associated with participation in the activities and events. Additionally, I, for me and my child, assume the risk of exposure to COVID-19 and all its variants. I, for me and my child, accept personal financial responsibility for any injury or other loss sustained during the events and activities, as well as for any medical treatment rendered to me or my child provided by Penn-Del or any of its volunteers, employees, or affiliate churches, their volunteers, or employees. Furthermore, I, for me and my child, release and promise to indemnify, defend, and hold harmless Penn-Del or any of its volunteers, employees, officers, or directors or affiliate churches, their volunteers, employees, officers, or directors for any injury or loss, arising directly or indirectly, out of the activities or events named or described above or from transportation to and from the activities or events named or described above, whether such injury or loss arises out of the negligence of Penn-Del, or any of its volunteers, employees, officers, or directors, or affiliate churches, their volunteers, employees, officers, or directors. If any claim for damages should arise related to any of the activities or events named or described above or any dispute develops over the interpretation of this Consent and Release of Liability, I, for me and my child, agree that all such disputes shall be resolved exclusively by arbitration in accordance with the rules of the American Arbitration Association. If you agree with the above Consent and Release form and intend to be legally bound, please sign with your signature below.
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PARENTAL PERMISSION & RELEASE FORM* This field is required. ARCHERY TAG: EXTREME ARCHERY. RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (AGREEMENT) (Form 3742) In consideration of participating in Archery Tag® extreme archery, I represent that I understand the nature of this activity and that I am qualified, in good health, and in proper physical condition to participate in such activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the activity. I fully understand that this activity involves risk of serious bodily injury which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “releases” named below; and that there may be other risks either not known to me or not readily foreseeable at this time: and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my own participation in the activity. I hereby release, discharge, and covenant not to sue PennDel District Council of the Assemblies of God (Bongiorno Conference Center), its respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors or premises on which the activity takes place, (each considered one of the “RELEASES” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence or the “releases” or otherwise, included negligent rescue operations; and I further agree that if, despite this release, waiver or liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the RELEASES, I will indemnify, save, and hold harmless each of the RELEASES from any loss, liability, damage, or cost which any may incur as the result of such claim. PARENT CONSENT FOR ARCHERY TAG I, the minor’s parent and /or legal guardian, understand the nature of the above referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activity. I hereby release, discharge, covenant not to sue and AGREE TO INDEMNITY AND SAVE AND HOLD HARMLESS each of the RELEASES from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the RELEASES or otherwise, including negligent rescue operations, and further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the above RELEASES, I WILL INDEMNITY, SAVE AND HOLD HARMLESS each of the RELEASES from any litigation expenses, attorney fees, loss liability, damage, or cost any RELEASES many incur as the result of any such claim. The signature(s) on this document binds the signee(s) to all consents, releases and waivers as spelled out on forms 3742. I have read this RELEASE AND WAIVER OR LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (FORM 3742) I understand that I have given up substantial rights by signing and have signed freely and without any inducement. If you agree with the above Consent and Release of Archery Tag release form and intend to be legally bound, please sign with your signature below.
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PARENTAL PERMISSION & RELEASE FORM* This field is required. TUBBY: Deerpath Tubing. RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT In consideration of participating in Tubby, Deerpath tubing, I represent that I understand the nature of this activity and that I am qualified, in good health, and in proper physical condition to participate in such activity. I acknowledge that if I believe event conditions are unsafe, I will immediately discontinue participation in the activity. I fully understand that this activity involves risk of serious bodily injury which may be caused by my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the “releases” named below; and that there may be other risks either not known to me or not readily foreseeable at this time: and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a result of my own participation in the activity. I hereby release, discharge, and covenant not to sue Penndel District Council of the Assemblies of God (Bongiorno Conference Center), its respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors or premises on which the activity takes place, (each considered one of the “RELEASES” herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence or the “releases” or otherwise, including negligent rescue operations; and I further agree that if, despite this release, waiver or liability, and assumption of risk I, or anyone on my behalf, makes a claim against any of the RELEASES, I will indemnify, save, and hold harmless each of the RELEASES from any loss, liability, damage, or cost which any may incur as the result of such claim. PARENT CONSENT FOR SLIDE I, the minor’s parent and /or legal guardian, understand the nature of the above referenced activities and the minor’s experience and capabilities and believe the minor to be qualified to participate in such activity. I hereby release, discharge, covenant not to sue and AGREE TO INDEMNITY AND SAVE AND HOLD HARMLESS each of the RELEASES from all liability, claims, demands, losses, or damages on the minor’s account caused or alleged to have been caused in whole or in part by the negligence of the RELEASES or otherwise, including negligent rescue operations, and further agree that if, despite this release, I, the minor, or anyone on the minor’s behalf makes a claim against any of the above RELEASES, I WILL INDEMNITY, SAVE AND HOLD HARMLESS each of the RELEASES from any litigation expenses, attorney fees, loss liability, damage, or cost any RELEASES many incur as the result of any such claim. The signature(s) on this document binds the signee(s) to all consents, releases, and waivers as spelled out in this document. I have read this RELEASE AND WAIVER OR LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT. I understand that I have given up substantial rights by signing and have signed freely and without any inducement. If you agree with the above Consent and Release of Deerpath tubing release form and intend to be legally bound, please sign with your signature below.
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WHAT WINTER RETREAT WILL YOU BE ATTENDING?* This field is required.
WEEKEND 1: January 10-12
WEEKEND 2: January 17-19
WEEKEND 3: January 24-26
Should be Empty: