CAMP BUCKEYE

CAMP BUCKEYE
Program Activity Waiver
www.campbuckeye.org
10055 Camp Road N.W. Beach City, Ohio 44608
Phone: 330-756-2380
ALL PARTICIPANTS MUST READ THIS RELEASE OF LIABILITY FORM
PRIOR TO SIGNING AND PARTICIPATING IN PROGRAM ACTIVITIES
Agreement to personally assume all risk and release of all claims for liability and waiver of right to sue based upon my
understanding of these activities and their inherent risks.
I (Full name)
of (city and state)
Having the date of birth

MonthDayYear
desire Camp Buckeye, a Ohio not for profit corporation, to permit me to participate in the following described activity.
General ActivitiesSwimmingSkeet ShootingPaintballHigh Adventure ActivitiesVolunteer Work
In order to participate in the above mentioned activities, I, the undersigned, agree and acknowledge that:
- There is risk of injury, including a potential for permanent disability or death resulting from any participation in the above mentioned activities and or from the equipment involved in participation in such activities.
- I freely assume all such risks, both known and unknown and assume full responsibility for my participation.
- I will read and understand the rules of play, including all safety rules, and agree to fully comply with the rules and safety regulations during my participation.
- I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin hereby release and hold harmless Camp Buckeye, their officers, officials, agents and or employees, from any and all liability for injury, disability, death, loss or damage to personal property.
- I acknowledge, understand and agree that I have read this release of liability and assume all risk associated with participating in the above mentioned activities and that I sign this release of liability voluntarily and without inducement.
- I certify I am able to take a full and active part in the program at Camp Buckeye.
- I further authorize Camp Buckeye to administer necessary medical treatment in case of accident or illness which occurs while a camper. I also realize that my picture or testimony may be used in promotion of the camp.
All program actives, and handling and use of program equipment must be supervised by Camp Buckeye Staff.
Participants Name (Please Print):
Date of Birth:

MonthDayYear
Date
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Cell:
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact:
Relationship:
Emergency Contact Phone:
Format: (000) 000-0000.
Insurance Carrier/ Number:
Participant Signature:
Date:

MonthDayYear
Date
YesNo
MINOR AGED PARTICIPANTS
All guests under the age of 18 at the time of participation must have a parent or guardian sign below.
I certify that I am the parent or guardian of
with legal responsibility for the above signed participant and
agree to his/her release and agree to indemnify the above named companies and individuals from all liabilities resulting from his/her
release and agree to indemnify the above named companies and individuals from all liabilities resulting from his/her participation in the
above mentioned program activities for myself, my heirs, assigns, and next of kin.
Parent or Guardian Signature:
Date:

MonthDayYear
Date
Should be Empty:

CAMP BUCKEYE

Program Activity Waiver

MINOR AGED PARTICIPANTS