Reach 2026 Release Forms

Kiamichi Baptist Assembly Health Form

P.O. Box 9, Talihina, OK 74571

Date of camp

Date

Church Name*

Church Phone*

Format: (000) 000-0000.

Church Address

Church City

Church State

Church Zip

Cabin you're staying in at KBA (do not complete this field)

Campers name*

Date of Birth*

Date

Male

Female

Home Address*

Address

Street Address Line 2

CityState

Zip

Social Security Number*

CDIB #

Home Phone# *

Format: (000) 000-0000.

Parent/Guardian Name or Adult Participant Name*

Emergency Phone#*

Format: (000) 000-0000.

Emergency Contact Person/Relationship*

NoYes

If yes list what you are allergic to

Medicines you are presently taking

Date of last tetanus shot

Date

YesNo

If yes, please explain (use the back of this paper if necessary)

Your physicians name

Office Phone

Format: (000) 000-0000.

Permission to receive medical help for camper if needed.

I/we (name typed below) parent/guardian of the above named camper, hereby give consent to provide this camper with emergency care, and/or hospitalization for any accident or illness which occurs while attending Kiamichi Baptist Assembly, and also give permission to transport camper to and from localities where such health services are provided.

Parent/Guardian or Adult Participant Name*

Signed*

Relationship*

Date Signed*

Date

STATEMENT (Must be signed by parent/guardian and camper

(or Adult Participant)

We have read or had read to us the KBA guidelines, rules and regulations. We agree that the above named camper will follow these rules while camping at KBA. We undersigned that KBA is not the responsible party for the supervision of the campers, but it is the responsibility of the church or group bringing them to the KBA campgrounds.

Parent/Guardian or Adult Participant Signature*

Date Signed*

Date

Student or Adult Participant Signature*

Date Signed*

Date

Health Insurance Information

Camp Ins. Coverage: American Income Life Insurance, P.O. Box 50158, Indianapolis, IN 46250, 1-800-849-4820

Accident coverage limit: $2,500; Sickness coverage limit: $750; Dental coverage limit: $300

Personal Insurance Coverage (Your Insurance) Company name*

Insurance Company Address and City*

Insurance Company State*

Insurance Company Zip*

Insurance Company Phone Number

Format: (000) 000-0000.

Insurance Policy #

Reach Medical Release Form Addendum for Students

AND Adults

The undersigned does hereby give permission for said participant to attend and participate in Reach Local Mission Projects and do hereby consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agrees to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned person pursuant to this authorization. Should it be necessary for participant to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Parent/Guardian Signature or Adult Participant if 18 or over*

Date*

Date

Reach Parent/Student Statement of Understanding & Release Form

Reach is designed to be a mission trip experience and our desire is to treat the week as if we were miles away from home. Students will gain the most from the experience if they are somewhat isolated from their normal routine and activities. Also because of crew organization and the amount of work that has to be completed, it is very important that we know exactly how many students will be working on each site every day. Therefore, it is the Reach policy that:

All students grades 6-12 are required to spend the night and be present from Wednesday-Sunday.
Students may not come and go during the week. If a student leaves, he/she will not be able to return unless there are EXTENUATING circumstances and there has been prior consent and a mutual agreement between parent/guardian/youth leader/Reach staff, including crew chief.
Students will be traveling in church vans and/or adult crew worker vehicles to and from worksites and worship.

Parents are welcome to attend the evening services. However, it has been our experience that it is best if parents do not come and go at the housing site or job site throughout the week. Remember, this week is just like an out-of-town mission trip or church camp and our desire is to create an environment where students bond with their crew and youth group in the most effective way.

We, the undersigned, understand and agree to the above for said participant. The undersigned also agrees to the use of any media (i.e. photos, videos, new articles, social media/Facebook/Instagram, etc) used by Reach.The undersigned does also hereby give permission for minor child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Reach.

Parent/Guardian Signature or Adult Participant if 18 or over*

Date*

Date

Student or Adult Participant Signature*

Date*

Date