Student Form - Annual Kids & Youth Retreat

Annual Kids & Youth Retreat Arabic Evangelical Church
Registration Form
Participant Information
Student Name

First NameLast Name
Age
D.O.B.

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Completed
Gender
Gender
T-Shirt Size
Name of Church Group
Email Address:
example@example.com
Parent/Guardian Information
Mother's Name

First NameLast Name
Mother's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother's Daytime Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Name

First NameLast Name
Father's Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Daytime Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Information
Emergency Contact (Other than Parents)
Relationship to participant
Daytime Phone Number
Format: (000) 000-0000.
Evening Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Please share with us any information about your Child's health, walk with God, or personal information that you feel necessary and important for us to know. Our goal is to make a difference in every Child's life by providing a positive building experience for them. ALL INFORMATION REMAINS CONFIDENTIAL.

Medical Consent Form
Student Name

First NameLast Name
Age
D.O.B.

MonthDayYear
Date
Do you carry family medical / Hospital insurance?
1. Insurance Information
Insurance Carrier and Policy Number
2. Responsible Party Information
Name of Responsible Party

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship to Participant
3. Physician Information
Name of Family Physician

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
4. Medical History
Are all Immunizations up to date?
Date of Last Tetanus Shot

MonthDayYear
Date
List of all Medication required during retreat
List of all Medical Conditions
List of all Allergies
By signing this form I give my informed consent to the First Aid personnel assigned by the Arabic Evangelical Church of Temple City who are certified in a minimum of CPR and First Aid to provide basic aid and comfort measures through standardized treatment procedures which include over-the-counter medications for treatment of minor problems including but not limited to wounds and cuts, fever, cough, throat pain, stomach ache, diarrhea and/or nausea. I allow my child to participate in the retreat's activities which include running, swimming and group games. I understand that my child's participation in these activities can expose him/her to dangers from known and unanticipated risks. Acknowledging that such risk exists, I on behalf of myself, my child and any other party who may have the right to assert any rights on behalf of my child, do hereby forever release and discharge the Arabic Evangelical Church of Temple City, Hope Harbor and any other person associated with this retreat from any claim, causes of action, suits, demands, losses, damages, expenses, costs or liability arising from or in connection with my child's participation in this retreat.

I have read and understood the entire form and by signing below, I agree to the terms herein.
Parents Name:
Parents Signature:
Date:

MonthDayYear
Date

WATER SLIDE WAIVER AND LIABILITY RELEASE
Name of Responsible Party:
Your group is requesting to use the water slide located at the pool on the premises of Hope Haven Conference Center. While we strive to maintain a safe environment, the use of the water slide involves certain inherent risks, including but not limited to the risk of injury. By signing this form, you acknowledge that:
- You are voluntarily choosing to use the water slide.
- You understand and accept that any use of the water slide is entirely at your group's own and exclusive risk.
- You agree to assume full responsibility for any and all injuries, damages, or losses that may occur as a result of using the water slide.
- You release Hope Haven Conference Center, its staff, volunteers, affiliates, and representatives from any and all liability, claims, or demands of any kind related to or arising from the use of the water slide.
Your use of this equipment constitutes your full acceptance of the risks and liabilities involved. By signing below, you acknowledge that you have read and understood this notice and agree to its terms.
Signature of Parent:
Printed Name:
Date:

MonthDayYear
Date

HOPE HARBOR Conference & Retreat Center
ZIPLINE ACTIVITY WAIVER OF LIABILITY

Parent / Guardian Assumption of Risk & Release Agreement
This agreement must be completed and signed by a parent or legal guardian for any minor participating
in the zipline activity at Hope Harbor.
Minor Participant Full Name
Date of Birth

MonthDayYear
Date
Parent / Legal Guardian Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.
Date of Activity

MonthDayYear
Date
ACKNOWLEDGMENT & ASSUMPTION OF RISK

I understand that participation in zipline activities involves inherent risks that cannot be completelyeliminated, even when all safety procedures and equipment are properly used. I knowingly andvoluntarily allow my child to participate with full understanding of these inherent risks.
PARENT / GUARDIAN REPRESENTATIONS

I certify that I am the lawful parent or legal guardian of the minor participant and that my child is physically and mentally capable of participating in this activity. I understand that my child must follow all instructions and safety rules provided by Hope Harbor staff and volunteers.

RELEASE & WAIVER OF LIABILITY

In consideration of my child being permitted to participate, I hereby release and hold harmless Hope Harbor, its directors, officers, employees, volunteers, and agents from any claims arising out of my child's participation, to the fullest extent permitted by law.
INDEMNIFICATION

I agree to indemnify and hold harmless Hope Harbor from any claims, liabilities, or expenses arising from my child's participation or failure to comply with safety rules.
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Parent/ Guardian Signature
This agreement shall be governed by and construed in accordance with the laws of the State of California.

Hope Harbor
Pool Waiver of Liability and Assumption of Risk
Location: Hope Harbor, 23064 Forlori Circle, Perris, CA 92570
Activity: Swimming Pool Use
This waiver is required for all individuals who wish to use the swimming pool facilities at Hope Harbor. Please read carefully before signing, as it affects your legal rights.
Voluntary Participation

I understand that use of the swimming pool and participation in related activities is voluntary. I recognize that these activities involve inherent risks including, but not limited to, slips, falls, drowning, and other injuries.
Assumption of Risk

I knowingly assume full responsibility for all risks, whether known or unknown, associated with my use of the pool and surrounding areas.
Supervision

There is no lifeguard on duty. Children under the age of 18 must be supervised by a responsible adult at all times. Running, rough play, diving in shallow areas, or unsafe behavior is not permitted in or around the pool.
Health & Safety

Individuals with open wounds, contagious conditions, or under the influence of drugs or alcohol may not use the pool. Proper swimwear is required at all times.
Release of Liability

I release and hold harmless Hope Harbor, its directors, staff, volunteers, and affiliates from any and all claims, demands, or causes of action arising from or connected with my use of the pool facilities.
Medical Authorization

In the event of an emergency, I authorize Hope Harbor staff or representatives to obtain medical treatment for me or my child(ren) as deemed necessary.
Group Responsibility

The designated group leader is responsible for ensuring that all participants are informed of these rulesand terms, and for collecting and submitting signed waivers for every individual (or parent/guardian for minors) before pool use. The leader must also ensure compliance with all pool rules during the event.
Acknowledgment and Agreement

By signing below, I acknowledge that I have read, understood, and agree to the terms of this waiver.
Participant Name
Date

MonthDayYear
Date
Signature
Parent/ Guardian (if under 18)
Signature
Date

MonthDayYear
Date
Should be Empty:

Annual Kids & Youth Retreat Arabic Evangelical Church

Registration Form

Participant Information

Parent/Guardian Information

Emergency Information

Medical Consent Form

1. Insurance Information

2. Responsible Party Information

3. Physician Information

4. Medical History

WATER SLIDE WAIVER AND LIABILITY RELEASE

HOPE HARBOR Conference & Retreat Center

ZIPLINE ACTIVITY WAIVER OF LIABILITY

ACKNOWLEDGMENT & ASSUMPTION OF RISK

PARENT / GUARDIAN REPRESENTATIONS

RELEASE & WAIVER OF LIABILITY

INDEMNIFICATION

Hope Harbor

Pool Waiver of Liability and Assumption of Risk

Voluntary Participation

Assumption of Risk

Supervision

Health & Safety

Release of Liability

Medical Authorization

Group Responsibility

Acknowledgment and Agreement