Medical Liability Release Form

Name of Camper

First name and last name

Age at Pine Valley

Information to be completed by parent:

Name of Parent

First name and last name

Home Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Parent's Home Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent's Work/Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Name of Guardian

Check box if camper has had any of the following:

Information about special conditions:

To the best of my knowledge, my child is in good health. I will notify the Camp if my child is exposed to aninfectious disease during the (3) weeks prior to arriving at camp. In the case of medical emergency, I understandevery effort will be made to contact parents or guardian. In the event I cannot be reached, I hereby give permission to the physician selected by the Camp Nurse to hospitalize, secure proper treatment, and order injections, anesthesia, or surgery for my child as named above.

Date

Parents Signature

Liability Release Form
This form MUST be completed for all campers age 18 and under attending Camp without a parent.

This form hereby signifies that I First Name* Last Name* of Street Address* City* State* Zip* do hereby remise, release and forever discharge the APOSTOLIC CHRISTIAN CHURCH PINE VALLEY RETREAT, and its administrators, agents, assigns, and personal representatives, of and from all manner of actions, causes of actions, claims and demands for, upon, or by reason of damage, loss or injury, which against the APOSTOLIC CHRISTIAN CHURCH PINE VALLEY RETREAT, I or my child ever had, now have, or which my child ever had, now has, or may have in the future, or which I or my child's heirs, executors, administrators, or personal representatives hereafter can, shall or may have for or by reason of any matter, cause, or thing whatsoever.

Email

example@example.com

Today's Date

Date

First Parent Signature

Second Parent Signature

Name of Camper