2026 Winter Retreat 11th Grade Liability Form

Guest Consent Release Form for Outside Groups Using YoungLife Camp - 11th Grade
NOTE TO GUEST: Young Life wants your experience at the Young Life camps to be a safe and healthy one. However, in the event of an accident or illness, it is important that we have the following information.
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Sex
Spouse/First Emergency Contact
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Emergency Contact
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Any allergies or other medical needs?
Name of Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I have had a physical within the last 24 months
Medical Insurance Company
Policy Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
INDEMNITY AND CONTRACT AGREEMENT:
I will not hold or attempt to hold Young Life liable for any loss, damage or injury to person or property caused by any act or neglect of other persons on or about the Property, or caused in any manner other than the willful or negligent act of Young Life, its agents and employees, and will indemnify and hold Young Life harmless from any liability for damages or claims against Young Life arising out of or in any way related to any such loss, damage or injury.

I release Young Life, including its trustees, employees and agents, from my physical injury, including death, or illness while at the Property. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.

AUTHORIZATION FOR TREATMENT:
I hereby give permission to the medical personnel selected by the camp director to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. To obtain a copy of Young Life’s Notice of Privacy Practices, log on to www.younglife.org or call (719) 867-3600.

I verify that I am or my child is in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the bounds of my physical health.

SAFETY:
Young Life is committed to the safety of all participants. I understand that weapons of any kind are not permitted at any Young Life activities, camps or events.

WAIVER AND RELEASE
If I am under the age of 18, or under the age of 19 if attending Malibu Club or Beyond Malibu, my parent or guardian, by signing below, also consent to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing below to defend, indemnify and hold Young Life harmless from any claim asserted by me against Young Life, including its trustees, employees and agents, if I should repudiate this release after obtaining adulthood.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Church/Group
Date of Event

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

ODPC Waiver & Release of Liability
I, the undersigned, FOR GOOD CONSIDERATION, the receipt of which is hereby acknowledged, jointly and severallyhereby forever release, discharge, acquit and forgive Open Door Presbyterian Church (hereinafter “ODPC”) and its agents and assigns from all actions, claims, demands, damages, obligations, liabilities, controversies and executions, of any kind or nature whatsoever, whether known or unknown, whether suspected or not, which have arisen, or may have arisen, or shall arise from incident(s) related to or arriving from my child's participation in any athletic and/or physical activity, whether organized or spontaneous, on the premises of the Open Door Presbyterian Church.

I specifically waive any claim or right to assert any cause of action or alleged cause of action or claim or demand which has, through oversight or error intentionally or unintentionally or through a mutual mistake, been omitted from this Waiver and Release of Liability.ThisWaiver and Release of Liability shall be binding upon and inure to the benefit of theparties, their successors, assigns and personal representatives.

Furthermore, in consideration for the rights and privileges associated with participation in any athletic and/or physica lactivity, I, the undersigned, acknowledge and agree to be bound by the following:

1. IDENTIFICATION OF RISKS. I understand that participation in any athletic and/or physical activity is dangerous,involves risk or serious injury, death, and other losses both to person and property. I understand that these injuries and losses might result not only from my action, but the actions, inaction or negligence of others.

2. ASSUMPTION OF THE RISKS. I agree that I am responsible for my safety while participating in athletic and/or physical activities and that such responsibility includes participating only when I am physically and mentally prepared toparticipate safely. I assume all risks associated with responsibility for any injury or loss connected with my participationin athletic and/or physical activities. I further agree that at any point, if I feel endangered either by my own action or those of others, I am free to withdraw from the athletic and/or physical activities and will do so of my own free will.

3. WAIVER. Aware of these risks and willing to assume them, I hereby waive, release and hold harmless ODPC and its affiliates, subsidiaries, officers, directors, employees, agents, coaches, doctors, officials, event organizers, volunteers, or sponsors (hereinafter “Released Parties”) from all claims, by me for any liability, injury, known or unknown, loss or damage in any way connected with my participation in athletic and/or physical activities. I intend for this Waiver and Release of Liability to also apply to any relatives, personal representatives, heirs, beneficiaries, next of kin or assigns whomight pursue any legal action or claim on my behalf.

4. APPLICABLE LAW. This Waiver and Release of Liability is formed under and is to be interpreted consistent with thelaws of the Commonwealth of Virginia.

5. INSURANCE. I currently have and agree to maintain valid and sufficient medical insurance throughout the time that Iparticipate in athletic and/or physical activities. I understand that this is my sole responsibility and I release ODPC from providing this coverage for me.

6. AUTHORIZATION FOR PHOTO/VIDEO USE. hereby grant Open Door Presbyterian Church (“ODPC”) the irrevocable right and permission to use my child’s name, likeness, image, voice, and/or appearance as such photographs and/or video recordings on ODPC and other websites and in publications, promotional flyers, educational materials, derivative works, or for any other similar purpose. I agree that ODPC has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with ODPC’s mission. I acknowledge that I will not receive any compensation, etc., for the use of such pictures, etc.

7. SIGNATURE. I acknowledge that I have read this Waiver and Release of Liability carefully and, having done so, signit voluntarily. I also hereby acknowledge that the information provided below is correct.
Print Full Name of Student

First NameLast Name
Signature of Student
Grade
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Print Full Name of Parent/Guardian

First NameLast Name
Signature

ODPC Medical Authorization Form

Grove Winter Retreat 2026
All medications must be in their original container in order to be administered during the 2026 Winter ODPC Retreat.
Student's Legal Full Name

First NameLast Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact 1

First NameLast Name
Relationship with Student
Emergency Contact 2

First NameLast Name
Relationship with Student
Allergies/ Reaction: Please list all allergies (medication,food, bee stings, poison ivy, etc.) and describe the nature of the reaction(Rash, hives, difficulty breathing, etc.,)
Medical Conditions: Please list all medical conditions(asthma, diabetes, cardiac disorders, history of heat illness or cramping,etc.)
Current Medication: Please include any medications that must be administered during the 2026 Winter ODPC Retreat.
Name of Medication (Including Strength)
Dosage to give
Frequency to be administered: (# of times per day or specific times) or symptoms that will necessitate administration of medication)
Route of Administration
Action to be taken if side effects are noted(Who should be contacted):
For Epi-Pens and inhalers: Check the box below if you authorize your child to carry his/her medication because there is a need for it be immediately accessible and your child can self-administer if needed.
Authorization to carry medication
Authorization to self-administer
INSURANCE INFORMATION
Health Insurance Company
Policy Number
Group Number
Name of Policy Holder
Relationship to Student
By signing below, I certify the following:

I am authorized to execute this document and make decision on behalf of my child as his/her parent or legal guardian. In an event, any accident, illness, injury or medical condition arises in connection with my child’s participation in the 2026 ODPC Winter Retreat, I hereby authorize OPDC, including any of its employees, staff or agents to obtain medical treatment for my child as the same may be deemed reasonably necessary by such parties and as a reasonable accommodation under the American with Disabilities Act (ADA).
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Students Name

First NameLast Name
Grade
Should be Empty:

Guest Consent Release Form for Outside Groups Using YoungLife Camp - 11th Grade

ODPC Waiver & Release of Liability

ODPC Medical Authorization Form