Camp Medical Information Release Form
  • Minor Medical Information Release form

  • Participant Information

  • Date of Birth*
     - -
  • Date of Camp*
     - -
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Emergency and Medical Provider Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Last Physical Exam
     - -
  • Is child current with immunization record?*
  • Health History and Medical Details

  • Date of Last Tetanus Shot*
     - -
  • Insurance Information

  • Do you have medical insurance?*
  • PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING ANGELES CREST CHRISTIAN CAMP FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFORE.

    Assumption of Risk I, in my legal capacity as the parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of Angeles Crest Christian Camp facilities, services, equipment and premises (“Facilities”) and any participation in Angeles Crest Christian Camp programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. Waiver, Release, Indemnification & Covenant Not to Sue In consideration of Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that Angeles Crest Christian Camp, it’s officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees.

    I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or death sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs.

    I hereby grant Angeles Crest Christian Camp the irrevocable and unrestricted right to use, publish, and distribute photographs, videos, or audio recordings for any lawful purpose, including commercial or promotional, without compensation. We waive any right to inspect or approve the finished materials and release Angeles Crest Christian Camp from any claims related to the use of minor’s likeness.

    Medical Release I hereby give my permission to the physician or dentist selected by Angeles Crest to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for the minor as deemed necessary if I am unable to give consent. I also authorize the first aid attendant on duty at Angeles Crest Christian Camp to administer medical aid as required for illness or injury under a physician's orders.

  • Signature Areas

  • Date *
     - -
  • Should be Empty: